Emergency Medical Care Protocols - Southern Nevada Health District

Transcription

CLARK COUNTY EMS SYSTEM
EMERGENCY MEDICAL CARE
PROTOCOLS
EFFECTIVE: JUNE 1, 2016
(Replaces October 7, 2015 Version)
PO BOX 3902 – LAS VEGAS, NV 89127
TABLE OF CONTENTS
Foreword .................................................................................................................................................................................... 5
Terms and Conventions.............................................................................................................................................................. 8
ADULT TREATMENT PROTOCOLS...................................................................................................................................... 10
General Adult Assessment ................................................................................................................................................ 11
General Adult Trauma Assessment ................................................................................................................................... 13
Abdominal Pain/Flank Pain, Nausea & Vomiting .............................................................................................................. 15
Acute Coronary Syndrome (Suspected) ............................................................................................................................ 17
Allergic Reaction ............................................................................................................................................................... 19
Altered Mental Status ....................................................................................................................................................... 21
Behavioral Emergencies .................................................................................................................................................... 23
Bradycardia ....................................................................................................................................................................... 25
Burns ................................................................................................................................................................................. 27
Cardiac Arrest (Non-Traumatic) ........................................................................................................................................ 29
Chest Pain ......................................................................................................................................................................... 31
Childbirth/Labor ................................................................................................................................................................ 33
Drowning ........................................................................................................................................................................... 35
Hyperkalemia (Suspected) ................................................................................................................................................ 37
Hyperthermia/Environmental Illness ................................................................................................................................ 39
Hypothermia/Environmental Illness ................................................................................................................................. 41
Obstetrical Emergency ...................................................................................................................................................... 43
Overdose/Poisoning .......................................................................................................................................................... 45
Pain Management ............................................................................................................................................................. 47
Pulmonary Edema/CHF ..................................................................................................................................................... 49
Respiratory Distress .......................................................................................................................................................... 51
Seizure ............................................................................................................................................................................... 53
Shock ................................................................................................................................................................................. 55
Smoke Inhalation .............................................................................................................................................................. 57
Stroke (CVA) ...................................................................................................................................................................... 59
Tachycardia/Stable............................................................................................................................................................ 61
Tachycardia/Unstable ....................................................................................................................................................... 63
Therapeutic Hypothermia & Post-Resuscitation Care ...................................................................................................... 65
Ventilation Management .................................................................................................................................................. 67
PEDIATRIC TREATMENT PROTOCOLS................................................................................................................................ 69
General Pediatric Assessment........................................................................................................................................... 70
General Pediatric Trauma Assessment ............................................................................................................................. 72
Abdominal/Flank Pain, Nausea & Vomiting ...................................................................................................................... 74
Allergic Reaction ............................................................................................................................................................... 76
Altered Mental Status ....................................................................................................................................................... 78
Behavioral Emergencies .................................................................................................................................................... 80
Bradycardia ....................................................................................................................................................................... 82
Burns ................................................................................................................................................................................. 84
Cardiac Arrest (Non-Traumatic) ........................................................................................................................................ 86
PEDIATRIC TREATMENT PROTOCOLS (Cont.)
Drowning
88
Hyperthermia/Environmental Illness
90
Hypothermia/Environmental Illness
92
Neonatal Resuscitation
94
Overdose/Poisoning
96
Pain Management
98
Respiratory Distress
100
Seizure
102
Shock
104
Smoke Inhalation
106
Tachycardia/Stable
108
Tachycardia/Unstable
110
Ventilation Management
112
OPERATIONS PROTOCOLS
114
Communications
115
Do Not Resuscitate (DNR/POLST)
117
Documentation
119
Hostile Mass Casualty Incident
120
Inter-Facility Transfer of Patients by Ambulance
121
Pediatric Patient Destination
122
Prehospital Death Determination
123
Public Intoxication
124
Quality Improvement Review
125
Termination of Resuscitation
126
Transport Destinations
127
Trauma Field Triage Criteria
128
Waiting Room Criteria
131
PROCEDURES PROTOCOLS
132
Cervical Stabilization
133
Continuous Positive Airway Pressure (CPAP)
134
Electrical Therapy/Defibrillation
135
Electrical Therapy/Synchronized Cardioversion
136
Electrical Therapy/Transcutaneous Pacing
137
Endotracheal Intubation
138
Extraglottic Device
140
First Response Evaluate/Release
141
Hemorrhage Control Tourniquet
142
Medication Administration
143
Needle Cricothyroidotomy
145
Needle Thoracentesis
146
Tracheostomy Tube Replacement
147
Traction Splint
148
PROCEDURES PROTOCOLS (Cont.)
Vagal Maneuvers............................................................................................................................................................. 149
Vascular Access ............................................................................................................................................................... 150
FORMULARY .................................................................................................................................................................. 151
Acetylsalicylic Acid (Aspirin) ............................................................................................................................................ 152
Activated Charcoal .......................................................................................................................................................... 152
Adenosine (Adenocard) .................................................................................................................................................. 153
Albuterol (Proventil) ....................................................................................................................................................... 153
Amiodarone (Cordarone) ................................................................................................................................................ 154
Atropine Sulfate .............................................................................................................................................................. 154
Bronchodilator MDI ........................................................................................................................................................ 155
Calcium Chloride ............................................................................................................................................................. 155
Diazepam (Valium) .......................................................................................................................................................... 156
Diphenhydramine Hydrochloride (Benadryl) .................................................................................................................. 156
Dopamine Hydrochloride (Intropin)................................................................................................................................ 157
Droperidol (Inapsine) ...................................................................................................................................................... 157
Epinephrine ..................................................................................................................................................................... 158
Epinephrine Auto-Injector .............................................................................................................................................. 158
Etomidate (Amidate) ....................................................................................................................................................... 159
Fentanyl Citrate (Sublimaze) ........................................................................................................................................... 159
Glucagon ......................................................................................................................................................................... 160
Glucose............................................................................................................................................................................ 160
Hydromorphone (Dilaudid) ............................................................................................................................................. 161
Hydroxocobalamin .......................................................................................................................................................... 161
Ipratroprium Bromide ..................................................................................................................................................... 162
Ipratroprium Bromide and Albuterol Sulfate (Duoneb) .................................................................................................. 162
Ketamine (Ketalar) .......................................................................................................................................................... 163
Lidocaine 2% Lubricant ................................................................................................................................................... 163
Magnesium Sulfate ......................................................................................................................................................... 164
Midazolam (Versed) ........................................................................................................................................................ 164
Morphine Sulfate ............................................................................................................................................................ 165
Naloxone Hydrochloride (Narcan) .................................................................................................................................. 165
Nitroglycerin ................................................................................................................................................................... 166
Ondansetron Hydrochloride (Zofran).............................................................................................................................. 166
Phenylephrine (Neo-Synephrine) .................................................................................................................................... 167
Sodium Bicarbonate ........................................................................................................................................................ 167
Solu-Cortef ...................................................................................................................................................................... 168
APPENDICES .................................................................................................................................................................. APP
First Response Low-Risk Alpha Evaluate and Release Form (example) ............................................................................. A
Release of Medical Assistance ............................................................................................................................................ B
Scope of Practice ................................................................................................................................................................. C
Receiving Hospital Directory .............................................................................................................................................. D
FOREWORD
EMERGENCY MEDICAL SERVICES
PROTOCOL MANUAL
Optimal prehospital care results from a combination of careful patient assessment, essential prehospital
emergency medical services, and appropriate medical consultation. The purpose of this manual is to
provide guidance for ALL prehospital care providers and emergency department physicians within the
Clark County EMS System.
The GOAL of the manual is to STANDARDIZE prehospital patient care in Clark County. It is to be
understood that these protocols are guidelines. Nothing contained in these protocols shall be
construed to expand the scope of practice of any licensed Attendant beyond that which is identified
in the Clark County Emergency Medical Services Regulations and these protocols (Appendix B).
NOTHING contained within these protocols is meant to delay rapid patient transport to a receiving
facility. Patient care should be rendered while en-route to a definitive treatment facility.
The General Assessment protocols must be followed in the specific sequence noted. For all other
treatment protocols, the algorithm defines the care every patient should receive, usually in the order described.
To maintain the life of a specific patient, it may be necessary, in rare instances, for the physician
providing on-line medical consultation, as part of the EMS consultation system, to direct a prehospital
provider in rendering care that is not explicitly listed within these protocols, to include administering a
patient’s own medications which are not part of the approved formulary. To proceed with such an
order, both the telemetry physician and the provider must acknowledge and agree that the patient's
condition and extraordinary care are not addressed elsewhere within these medical protocols, and
that the order is in the best interest of patient care. Additionally, the provider must feel capable, based
on the instructions given by the telemetry physician, of correctly performing the directed care.
Whenever such care is provided, the telemetry physician and the provider must immediately notify the
Office of EMS & Trauma System (OEMSTS) of the extraordinary care situation. In addition, the
provider must immediately, upon completion of the call, make available the prehospital care
record and documentation specifying the nature of the deviation and the ordering physician’s
name to the OEMSTS. All such incidents will be entered into the Quality Improvement Review
process.
Occasionally a situation may arise in which a physician's order cannot be carried out, e.g., the
provider feels the administration of an ordered medication would endanger the patient, a medication
is not available, or a physician's order is outside of protocol. If this occurs, the provider must
immediately notify the telemetry physician as to the reason the order cannot be carried out, and
indicate on the prehospital care record what was ordered, the time, and the reason the order could
not be carried out. In addition, the provider must immediately notify the OEMSTS, and upon completion
of the call, make available the prehospital care record to the OEMSTS. All such incidents will be
entered into the Quality Improvement Review process.
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Protocol Key:
Caution / Warning / Alert
Pediatric Treatment Consideration (for patients less than 12 years of age)
Telemetry Contact Required
Specific Protocol
E
EMT Licensed Attendant and above may perform these steps
A
AEMT Licensed Attendant and above may perform these steps
P
Paramedic Licensed Attendant
Definition of a patient:
A patient is any individual that meets at least one of the following criteria:
1) A person who has a complaint or mechanism suggestive of potential illness or injury;
2) A person who has obvious evidence of illness or injury; or
3) A person identified by an informed 2nd or 3rd party caller as requiring evaluation for
potential illness or injury.
Pediatric patient considerations:
For patients <18 years old, use the Pediatric Patient Destination protocol.
Pediatric treatment protocols are to be used on children who have not yet experienced
puberty. Signs of puberty include chest or underarm hair on males, and any breast
development in females.
These protocols have been developed specifically for the Clark County EMS System and
represent consensus among all of the Clark County EMS agency medical directors and the Chief
Health Officer. The protocols demonstrate a commitment to a consistent approach to quality patient care.
From time to time, protocols may be added or revised by the Chief Health Officer upon recommendation
by the Medical Advisory Board (MAB). Additional recommendations are welcome and appreciated
at any time. They may be submitted to the OEMSTS for consideration and referral to the Medical
Advisory Board.
Southern Nevada Health District
Office of Emergency Medical Services & Trauma System
P.O. Box 3902
Las Vegas, Nevada 89127
Physical address:
280 S Decatur Blvd
Las Vegas, NV 89152
Office Hours: Mon-Fri 8:00 am to 4:30 pm
Questions may also be telephoned to EMS staff at (702) 759-1050, or visit our website at
http://www.southernnevadahealthdistrict.org/ems/index.php.
6
Chief Health Officer: Joseph P. Iser, MD, DrPh, MSc
EMS Agency Medical Directors who serve on the Medical Advisory Board:
Christian Young, MD, (Interim) Boulder City Fire Department
Dale Carrison, DO, Clark County Fire Department
Tressa Naik, MD, Henderson Fire Department
David Slattery, MD, FACEP, Las Vegas Fire & Rescue
Jarrod Johnson, MD, Mesquite Fire & Rescue
Alexander Malone, MD, North Las Vegas Fire Department
Edwin Homansky, MD, & Mike Barnum, MD, American Medical Response
Bryan Bledsoe, DO, & Eric Anderson, MD, MedicWest Ambulance
Logan Sondrup, MD, Community Ambulance
EMS Staff:
Christian Young, MD, EMS & Trauma System Medical Director [[email protected]]
John Hammond, BS, Paramedic, EMS & Trauma System Manager [[email protected]]
Laura Palmer, Paramedic, EMS & Trauma System Supervisor [[email protected]]
Gerry Julian, NR Paramedic, EMS Field Representative [[email protected]]
Rae Pettie, EMSTS Program/Project Coordinator [[email protected]]
Judy Tabat, EMSTS Program/Project Coordinator [[email protected]]
Michelle Stanton, Senior Administrative Assistant [[email protected]]
Special Thanks:
The OEMSTS and MAB would like to express appreciation to Dr. Kelly Morgan for her leadership
and commitment to the development of this manual.
Hospitals:
Boulder City Hospital: 901 Adams Blvd, Boulder City, NV 89005 (702) 293-4111
Centennial Hills Hospital: 6900 N Durango Dr, Las Vegas, NV 89149 (702) 629-1210
Desert Springs Hospital Medical Center: 2075 E Flamingo Blvd, Las Vegas, NV 89119 (702) 369-7772
Mesa View Regional Hospital: 1299 Bertha Howe Ave, Mesquite, NV 89027 (702) 756-3408
Mike O’Callaghan Federal Medical Center: 4700 N Las Vegas Blvd, Las Vegas, NV 89115 702) 653-3682
MountainView Hospital: 3100 N Tenaya, Las Vegas, NV 89128 (702) 345-4270
North Vista: 1409 E Lake Mead Blvd North, Las Vegas, NV 89030 (702) 657-5512
Southern Hills Hospital: 9300 W Sunset, Las Vegas, NV 89148 (702) 880-2800
Spring Valley Hospital & Medical Center: 5400 S Rainbow, Las Vegas, NV 89118 (702) 853-3611
St. Rose De Lima: 102 E Lake Mead Dr, Henderson, NV 89015 (702) 616-4600
St Rose San Martin: 8280 W Warm Springs, Las Vegas, NV 89113 (702) 492-8600
St Rose Siena: 3001 St Rose Pkwy, Henderson, NV 89052 (702) 616-5600
Summerlin Hospital Medical Center: 657 N Town Center Dr, Las Vegas, NV 89144 (702) 233-7000
Sunrise Hospital & Medical Center: 3186 S Maryland Pkwy, Las Vegas, NV 89106 (702) 731-8000
University Medical Center: 1800 W Charleston Las Vegas, NV 89102 (702) 383-2211
Valley Hospital Medical Center: 620 Shadow Ln, Las Vegas, NV 89106 (702) 388-4000
7
TERMS AND CONVENTIONS
AED
means Automated External Defibrillator
AMPLE
means Allergies; Medications; Prior history; Last meal eaten; Events leading up
to injury/illness
AMS
means Altered Mental Status
ASA
means Acetylsalicylic Acid
BG
means Blood Glucose
BP
means Blood Pressure
BVM
means Bag-Valve-Mask
CCC
means Continuous Cardiac Compressions
CHF
means Congestive Heart Failure
COPD
means Chronic Obstructive Pulmonary Disease
CP
means Chest Pain
CPR
means Cardiopulmonary Resuscitation
CVA
means Cardiovascular Accident
DCAP-BTLS
means Deformities; Contusions; Abrasions; Punctures/Penetrations;
Burns; Tenderness; Lacerations; Swelling
DKA
means Diabetic Ketoacidosis
ECG
means Electrocardiogram
ETA
means Estimated Time of Arrival
ETT
means Endotracheal Tube
GCS
means Glasgow Coma Scale
GU
means Genitourinary
HEENT
means Head, Ears, Eyes, Nose, Throat
HPI
means History of Present Illness
HR
means Heart Rate
ICP
means Intracranial Pressure
IM
means Intramuscular
IN
means Intranasal
IO
means Intraosseous
IV
means Intravenous
IVP
means Intravenous Push
IVPB
means Intravenous Piggyback
JVD
means Jugular Venous Distention
8
MAD
means Mucosal Atomizer Device
MI
means Myocardial Infarction
MOI
means Mechanism of Injury
NRB
means Non-rebreather
NS
means Normal Saline
NV
means Nausea/Vomiting
OEMSTS
OPQRST
means Office of Emergency Medical Services & Trauma System
means Onset; Provokes; Quality; Radiates; Severity; Time (used in evaluating
localized pain)
PCI
means Percutaneous Coronary Intervention
PCR
means Patient Care Record/Report
PO
means By Mouth
PRN
means As Needed
q
means Every
ROSC
means Return of Spontaneous Circulation
RR
means Respiratory Rate
RUQ
means Right Upper Quadrant
SAMPLE
means Symptoms; Allergies; Medications; Prior history; Last meal eaten;
Events leading up to injury/illness
SL
means Sublingual
SOB
means Shortness of Breath
S/P
means Status/Post
SQ
means Subcutaneous
S/S
means Signs/Symptoms
SVT
means Supraventricular Tachycardia
TCAs
means Tricyclic Antidepressants
TFTC
means Trauma Field Triage Criteria
TIA
means Transient Ischemic Attack
TKO/KVO
means To Keep Open/Keep Vein Open
VF
means Ventricular Fibrillation
VT
means Ventricular Tachycardia
VS
means Vital Signs
WPW
means Wolff-Parkinson-White Syndrome
9
ADULT
TREATMENT
PROTOCOLS
10
General Adult Assessment
Scene Safety / Scene Size-Up
Nature of Call / Mechanism of Injury
PPE / BSI
Bring all equipment to patient’s side
S.T.A.R.T. Triage
Unresponsive
Level of Consciousness
Check Pulse
Signs of Compromise or Not Protecting
Airway
Inadequate or Respiratory Distress
Breathing
Bleeding
Circulation
Altered or Confused
Disability
None
Cardiac Arrest
General Trauma
Altered Mental Status/
Syncope
History – HPI & AMPLE
Vital Signs & Physical Exam
E
Blood glucose testing as indicated
Specific treatment protocol as indicated
Cervical Stabilization as indicated
Comfort measures (splint, position of comfort)
P
Cardiac monitor as indicated
A
Vascular Access as indicated
Oxygen therapy to keep SpO2 >94%
P
Pain Management as indicated
Transport to closest facility for:
- Airway emergencies (unable to
oxygenate/ventilate)
Radio Contact for all Trauma Center patients, Code 3
returns; need for telemetry physician & as per protocol
Transport per Disposition Criteria, if applicable
General Adult Assessment Protocol
11
Pearls
· For all scenes where patient needs exceed available EMS resources, initial
assessment and treatment shall be in accordance with an approved triage
methodology.
· Correct life-threatening problems as identified.
· If the ability to adequately ventilate a patient cannot be established, the patient
must be transported to the nearest emergency department.
· Never withhold oxygen from a patient in respiratory distress.
· Contact with online medical control should be established by radio. Telephone
contact may only be used if the call is routed via a recorded phone patch through
FAO at 702-382-9007.
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Disposition
Patients sustaining traumatic injuries shall be transported in accordance with the Trauma Field Triage Criteria Protocol.
Patients sustaining burn injuries shall be transported in accordance with the Burns Protocol.
Pediatric patients (<18 y/o for transport purposes only) shall be transported in accordance with the Pediatric
Destination Protocol.
Patients with evidence of a stroke shall be transported in accordance with the Stroke (CVA) Protocol.
Sexual assault victims <13 y/o shall be transported to Sunrise Hospital.
Sexual assault victims 13 y/o up to 18 y/o shall be transported to Sunrise Hospital or UMC.
Sexual assault victims 18 y/o and older shall be transported to UMC.
For sexual assault victims outside a 50-mile radius from the above facilities, the patient shall be transported to the
nearest appropriate facility.
Stable patients shall be transported to the hospital of their choice, if the patient has no preference the patient should
be transported to the closest facility.
For patients outside a 50 mile radius from protocol designated transport destinations, the licensee providing
emergency medical care shall transport the patient to the nearest appropriate facility.
Waiting Room Placement
A patient not on a legal psychiatric hold meeting all of the following criteria may be placed in the hospital waiting room
or other appropriate location:
HR 60 - 100
RR 10 - 20
Systolic BP 100 - 180
Diastolic BP 60 - 100
Room air pulse oximetry >94%
Alert and oriented x 4
Did NOT receive any parenteral medication during EMS transport except a single dose of Morphine Sulfate and/or
Ondansetron.
In the opinion of the Paramedic/EMT-P, does not require continuous ECG monitoring. Note: Any ECG monitoring
initiated by a transferring facility may not be discontinued by EMS personnel.
Does not require IV fluids (saline lock is permissible).
Can maintain a sitting position without adverse effects on their medical condition.
A complete PCR is left/transmitted and verbal notification given to hospital personnel.
Internal Disaster
If a hospital declares an internal disaster, that facility is to be bypassed for all patients except patients in cardiac arrest
or in whom the ability to adequately ventilate has not been established.
Operational exceptions may be initiated in regard to transport to hospitals on internal disaster.
General Adult Assessment Protocol
12
General Adult Trauma Assessment
GCS <8
E
BVM if O2 sat ≤ 94%
E
Oxygen Keep SpO2 >94%
Palpable
radial pulse?
No
A
GCS >8
Glasgow Coma
Score
Yes
A
Vascular Access
Vascular Access
1L NS bolus
E
Secondary Survey
Suspected tension pneumothorax
P
Sucking chest wound
E
Apply 3-sided occlusive dressing
Control active hemorrhage
E
Obvious fractures
E
Suspected traumatic brain injury
E
P
Immobilize fractures; assess distal
pulse
Raise Head of bed 30 degrees &
Capnography–ETCO2 35mmHg
Open wounds
E
P
Cover with gauze; wet trauma
dressing for abdominal evisceration
Pain Management
Transport & Radio Contact to
appropriate Trauma Center based on TFTC
General Adult Trauma Assessment Protocol
13
History
· Time and mechanism of injury
· Damage to structure or vehicle
· Location in structure or vehicle
· Others injured or dead
· Speed and details of MVC
· Restraints/protective equipment
· Past medical history
· Medications
Signs and Symptoms
· Pain, Swelling
· Deformity, lesions, bleeding
· AMS or unconscious
· Hypotension or shock
· Arrest
Differential (life threatening)
· Tension pneumothorax
· Flail chest
· Pericardial tamponade
· Open chest wound
· Hemothorax
· Intra-abdominal bleeding
· Pelvis/femur fracture
· Spine fracture/cord injury
· Head injury
· Extremity fracture
· HEENT (airway obstruction)
· Hypothermia
Pearls
· Recommended exam: Mental Status, Skin, HEENT, Heart, Lung, Abdomen,
Extremities, Back, Neuro.
· Transport destination is based on the Trauma Field Triage Criteria Protocol.
· Transport should not be delayed for procedures; ideally procedures should be
performed enroute when possible.
· BVM is an acceptable method of ventilating and managing an airway if pulse
oximetery can be maintained ≥90%.
· Geriatric patients should be evaluated with a high index of suspicion; occult injuries
may be present and geriatric patients can decompensate quickly.
General Adult Trauma Assessment Protocol
14
Abdominal / Flank Pain, Nausea & Vomiting
P
12-Lead ECG if age >35 yrs
Signs of
hypovolemia?
Yes
No
Vascular Access
A
Nausea or
vomiting?
500 ml NS bolus;
may repeat up to 2000 ml
Yes
P
No
Consider
Acute Coronary Syndrome
P
Consider
Pain Management
Continue General Adult Assessment
Abdominal / Flank Pain, Nausea & Vomiting Protocol
15
Consider an Anti-emetic:
ONDANSETRON
4.0 mg ODT/IM/IV
or
DROPERIDOL
1.25mg IM/IV/IO
History
· Age
· Medical/surgical history
· Onset
· Quality
· Severity
· Fever
· Menstrual history
Signs and Symptoms
· Pain location
· Tenderness
· Nausea
· Vomiting
· Diarrhea
· Dysuria
· Constipation
· Vaginal bleeding/discharge
· Pregnancy
Differential
· Liver (Hepatitis)
· Gastritis
· Gallbladder
· MI
· Pancreatitis
· Kidney stone
· Abdominal aneurysm
· Appendicitis
· Bladder/prostate disorder
· Pelvic (PID, ectopic pregnancy, ovarian
cyst)
· Spleen enlargement
· Bowel obstruction
· Gastroenteritis
· Ovarian and testicular torsion
Pearls
·
·
·
·
·
·
·
Recommended Exam: Mental Status, Skin, HEENT, Heart, Lung, Abdomen, Back,
Extremities, Neuro.
Neuro disorders or signs of hypoperfusion/shock in the presence of abdominal pain may
indicate an aneurysm.
Document mental status and vital signs prior to administration of anti-emetics & pain
management.
Repeat vital signs after each fluid bolus
In patients ≥35 years old consider cardiac origin and perform a 12-Lead ECG.
Consider retroperitoneal palpation for kidney pain.
Abdominal pain in women of childbearing age should be considered pregnancy until proven
otherwise.
Abdominal / Flank Pain, Nausea & Vomiting Protocol
16
Acute Coronary Syndrome (Suspected)
P
12-Lead ECG
STEMI
A
E
E
Non-Diagnostic 12-Lead
Vascular Access
Oxygen
Keep SpO2 >94%
A
E
ASPIRIN
324 mg PO
E
NITROGLYCERIN
E
Assist pt with own NTG as
prescribed; may repeat x 3
P
0.4 mg SL;
may repeat q 5 min x 3
P
P
Nitroglycerin is contraindicated in any
patient with hypotension, bradycardia,
tachycardia (HR >100 bpm) in the absence
of heart failure, and evidence of a right
ventricular infarction. Caution is advised
in patients with Inferior Wall STEMI and a
right-sided ECG should be performed to
evaluate RV infarction.
Pain Management for
continued pain
Consider Anti-emetic
for nausea/vomiting:
ONDANSETRON
4.0 mg ODT/IM/IV
or
DROPERIDOL
1.25 mg IM/IV/IO
ASPIRIN
324 mg PO
NITROGLYCERIN
E
Assist pt with own NTG as
prescribed; may repeat x 3
P
0.4 mg SL;
P
Pain Management
for continued pain
P
Consider Anti-emetic
for nausea/vomiting:
ONDANSETRON
4.0 mg ODT/IM/IV
or
DROPERIDOL
1.25 mg IM/IV/IO
Refer to Arrhythmia and
Shock Protocols as needed
Transport to and Notify Receiving
Hospital
Vascular Access
Oxygen
Keep SpO2 >94%
Transport to Hospital of Patient’s
Choice
Acute Coronary Syndrome (Suspected) Protocol
17
History
· Age
· Medication: Viagra, Levitra, Cialis
· Past medical history of MI,
angina, diabetes
· Allergies
· Recent physical exertion
· Palliation, provocation
· Quality
· Region, radiation, referred
· Severity (1-10)
· Time of onset, duration,
repetition
Signs and Symptoms
· CP, pressure, ache, vice-like
pain, tight
· Location, substernal, epigastric,
arm, jaw, neck, shoulder
· Radiation of pain
· Pale, diaphoresis
· Shortness of breath
· Nausea, vomiting, dizziness
· Time of onset
Differential
· Trauma vs medical
· Anginal vs MI
· Pericarditis
· Pulmonary embolism
· Asthma, COPD
· Pneumothorax
· Aortic dissection or aneurysm
· GE reflux or hiatal hernia
· Esophageal spasm
· Chest injury or pain
· Pleural pain
· Drug overdose (cocaine,
methamphetamine)
Pearls
· Recommended exam: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Back,
Extremities, Neuro.
· Diabetics, geriatrics and female patients often have atypical pain. Have a high index of
suspicion.
· Perform a 12-Lead ECG on all patients 35 years old or older experiencing vague jaw/
chest/abdominal discomfort.
· Perform a 12-Lead ECG as quickly as practicable.
QI Metrics
· 12-Lead ECG within 5 minutes of patient contact.
· Pain reassessed after every intervention.
Acute Coronary Syndrome (Suspected) Protocol
18
Allergic Reaction
Evidence of airway
involvement/breathing
difficulties?
No
Yes
A
A
Vascular Access
DIPHENHYDRAMINE
50 mg IM/IV
EPINEPHRINE
E
Assist patient with own
auto-injector
A
Epinephrine
1:1000, 0.5 mg IM;
may repeat q 15 min
up to max 1.5 mg
Reassess patient q 5 min
Patient in shock?
Yes
No
ALBUTEROL
E
Assist patient with MDI
A
2.5 mg SVN; repeat as needed
A
P
Cardiac monitor
A
IV access
500 cc NS bolus;
may repeat up to 2L
A
DIPHENHYDRAMINE
50 mg IM/IV
P
EPINEPHRINE
1:10,000
0.1mg IV/IO q 1 min
P
Cardiac monitor
A
IV access
500 cc NS bolus;
may repeat up to 2L
A
DIPHENHYDRAMINE
50 mg IM/IV
Notify Receiving Hospital
Allergic Reaction Protocol
19
ALBUTEROL 2.5 mg SVN;
repeat as needed
History
· Onset and location
· Insect sting or bite
· Food allergy/exposure
· Medication allergy/exposure
· New clothing, soap, detergent
· Past history of reactions
· Medication history
Signs and Symptoms
· Itching or hives
· Coughing/wheezing or
respiratory distress
· Throat or chest constriction
· Difficulty swallowing
· Hypotension/shock
· Edema
· Nausea/vomiting
Differential
· Urticarial (rash only)
· Anaphylaxis (systemic effect)
· Shock (vascular effect)
· Angioedema (drug induced)
· Aspiration/airway obstruction
· Asthma/COPD
· CHF
Pearls
· Recommended Exam: Mental Status, Skin, Heart, Lung.
· Anaphylaxis is an acute and potentially lethal multisystem allergic reaction.
· Epinephrine is a first-line drug that should be administered in acute anaphylaxis
(moderate / severe symptoms). IM Epinephrine (1:1,000) should be administered in
priority before or during attempts at IV or IO access.
· Anaphylaxis refractory to repeat doses of IM Epinephrine may require IV Epinephrine
(1:10,000) administration by IV push or Epinephrine infusion.
· Contact Medical Control for refractory anaphylaxis.
· Consider ETCO2 monitoring.
Severity
·
Mild reactions involve skin rashes, itchy sensation, or hives with no respiratory
involvement.
·
Moderate reactions involve skin disorders and may include some respiratory involvement
like wheezing, yet the patient still maintains good tidal volume air exchange.
·
Severe reactions involve skin disorders, respiratory difficulty, and may include hypotension.
Special Considerations
·
·
·
Always perform ECG monitoring when administering Epinephrine.
Consider Dopamine for hypotension refractory to administration of Epinephrine.
Provide oxygen and airway support as needed.
QI Metrics:
·
·
Epinephrine given appropriately.
Airway assessment documented.
Allergic Reaction Protocol
20
Altered Mental Status / Syncope
BG <60mg/dl
E
ORAL GLUCOSE
if patient protecting airway
A
D10, 25g IV ;
(250mL of 10% solution) ;
may repeat x 1 in 5 min
GLUCAGON
1.0 mg IM for no IV access
E
Blood glucose testing
A
Vascular Access
No
BG >60mg/dl
P
A
Improved mental
status?
Cardiac monitor
12-Lead ECG
Consider NS 500 ml IV;
may repeat up to 2000 ml
Consider the
following:
Yes
Other treatment protocols as
indicated
Unresponsive with
respiratory depression &
suspected narcotic
overdose
A
Signs of stroke?
Stroke
Signs of hypoperfusion?
Shock
Signs of a seizure of
post-ictal state?
Seizure
Signs of trauma or head
injury?
General Trauma
Cardiac causes/
known disease?
Appropriate cardiac
protocol
NALOXONE
0.4 – 2.0 mg IN/IM/IV;
may repeat 2.0 mg IN/IM/IV
if patient slow to respond;
titrate to effect;
max dose 10 mg
Altered Mental Status / Syncope Protocol
21
21 Revised 6/03/2015
Poisoning/Overdose
History
· Known diabetic, Medic Alert tag
· Drugs or drug paraphernalia
· Report of drug use or toxic
ingestion
· Medications
· History of trauma
· Change in condition
· Changes in feeding or sleep
habits
Signs and Symptoms
· Decreased mental status or
lethargy
· Changes in baseline mental
status
· Bizarre behavior
· Hypoglycemia
· Hyperglycemia
· Irritability
Differential
· Head trauma
· CNS (stroke, tumor, seizure, infection)
· Cardiac (MI, CHF)
· Hypothermia
· Infection
· Thyroid
· Shock (septic, metabolic, traumatic)
· Diabetes
· Toxicological or ingestion
· Acidosis/Alkalosis
· Environmental exposure
· Hypoxia
· Electrolyte abnormality
· Psychiatric disorder
Pearls
·
·
·
·
·
Recommended Exam: Mental Status, HEENT, Skin, Heart, Lung, Abdomen, Back Extremities,
Neuro.
Pay careful attention to the head exam for signs of injury.
Be aware of AMS as presenting sign of an environmental toxin or Haz-Mat exposure, and
protect personal safety and that of other responders.
Do not let alcohol confuse the clinical picture; alcohol is not commonly a cause of total
unresponsiveness to pain.
If narcotic overdose or hypoglycemia is suspected, administer Narcan or Glucose prior to
advanced airway procedures.
Altered Mental Status / Syncope Protocol
22
Behavioral Emergency
Scene Safety
Consider medical causes for the
patient’s behavior:
1. Hypoxia
2. Intoxication / Overdose
3. Hypoglycemia / Electrolytes
4. Head Injury
5. Post-ictal State
6. Excited Delirium
Implement the
S.A.F.E.R. model
Threatened or acted in a way that suggests threat to self or others?
Yes
Yes
No
Threatened to
harm SELF
Threatened to
harm OTHERS
No threats to
self or others
4-point restraints; hood
if indicated; NO PRONE
POSITION
Transport
2-point restraints;
consider law
enforcement escort; or
4-point restraints if
needed
Consider a flight risk
Persistent risk
Transport
P
MIDAZOLAM
0.1 mg/kg IN/IM/IV;
may repeat q 5 min at
0.05 mg/kg
OR
DIAZEPAM
5.0 mg IV; may
repeat q 5 min
OR
DROPERIDOL
1.25 mg IM/IV/IO followed
by a saline flush or bolus;
may repeat dose q 5 min
OR KETAMINE
2.0 mg/kg IV/IO OR
4.0 mg/kg IM
Cardiac monitor
Behavioral Emergency Protocol
23
Continue General Adult
Assessment
History
· Situational crisis
· Psychiatric illness/medications
· Injury to self or threats to others
· Medic Alert tag
· Substance abuse/overdose
· Diabetes
Signs and Symptoms
· Anxiety, agitation, confusion
· Affect change, hallucinations
· Delusional thoughts, bizarre
behavior
· Combative, violent
· Expression of suicidal/
homicidal thoughts
Differential
· AMS differential
· Alcohol intoxication
· Toxin/substance abuse
· Medication effect or overdose
· Withdrawal syndromes
· Depression
· Bipolar
· Schizophrenia
· Anxiety disorder
Pearls
·
·
·
·
·
·
·
Law enforcement assistance should be requested on all calls involving potentially
violent patients.
Under no circumstances are patients to be transported restrained in the prone
position.
Recommended Exam: Mental Status, Skin, Heart, Lung, Neuro.
Consider all possible medical/trauma causes for behavior.
Do not irritate the patient with a prolonged exam.
EMS providers are mandatory reporters in regard to suspected abuse of any
vulnerable person.
Consider ETCO2 monitoring.
Excited Delirium Syndrome
· Medical emergency-combination of delirium, psychomotor agitation, anxiety,
·
·
hallucinations, speech disturbances, disorientation, violent behavior, insensitivity
to pain, hyperthermia, and increased strength.
Potentially life threatening, and associated with the use of physical control
measures including restraints, TASER, or similar device.
Most common in male subjects with a history of serious mental illness and/or
acute or chronic drug abuse, particularly stimulants.
Dystonic Reaction
·
·
·
Condition causing involuntary muscle movements or spasms typically of the face, neck and
upper extremities.
Typically an adverse reaction to drugs such as Haloperidol (may occur with administration).
When recognized, administer Diphenhydramine 50 mg IM/IV/IO.
S.A.F.E.R.
·
·
·
·
·
Stabilize the situation by containing and lowering the stimuli.
Assess and acknowledge the crisis.
Facilitate the identification and activation of resources (chaplain, family, friends or police).
Encourage patient to use resources and take actions in his/her best interest.
Recovery or referral – leave patient in care of responsible person or professional, or
transport to appropriate facility.
Behavioral Emergency Protocol
24
Bradycardia
A
Vascular Access
P
Cardiac monitor/12-Lead ECG
(Suspected)
Signs of
hypotension,
AMS, shock
HR <50 bpm & ANY of the following:
1. Hypoperfusion
2. Altered mental status
3. Signs of shock
No
P
Consider Transcutaneous
Pacing
P
Consider:
ATROPINE
0.5 mg IVP;
may repeat q 3-5 min;
max dose 3.0 mg
Yes
Observe
Transport
P
ATROPINE
0.5 mg IVP; may repeat q 3-5 min;
max dose 3.0 mg
Refractory
P
Transcutaneous Pacing
Failure to capture
Responsive to
ATROPINE
ECG shows STEMI
Consider:
DOPAMINE
P
5-10 mcg/kg/min IV; titrate to SBP
100 mmHg; max dose 20 mcg/kg/min
P
P
Consider:
GLUCAGON
1 mg IV for patients on beta blockers
CALCIUM CHLORIDE
1.0 g IV for patients on calcium
channel blockers
Repeat 12-Lead ECG
Bradycardia Protocol
25
History
· Medications
· Pacemaker
Signs and Symptoms
· HR <60/min with hypotension,
acute AMS, chest pain, acute
CHF, seizures, syncope, or
shock secondary to bradycardia
· Respiratory distress
Differential
· Acute myocardial infarction
· Hypoxia
· Pacemaker failure
· Hypothermia
· Sinus bradycardia
· Athletic
· Head injury (elevated ICP) or stroke
· Spinal cord lesion
· AV block
· Overdose
Pearls
· Recommended Exam: Mental Status, HEENT, Heart, Lung, Neuro.
· Bradycardia causing symptoms is typically <50/minute. Rhythm should be
interpreted in the context of symptoms and pharmacological treatment given only
when symptomatic, otherwise monitor and reassess.
· Identifying signs and symptoms of poor perfusion caused by bradycardia are
paramount.
· Do not delay pacing while waiting for IV access.
· Hypoxemia is a common cause of bradycardia; be sure to oxygenate the patient
and provide ventilatory support as needed.
QI Metrics
· High degree blocks correctly identified.
· Pacer pads on patient if Atropine given.
· Patient paced if appropriate.
Bradycardia Protocol
26
Burns
Thermal Exposure
Chemical / Electrical Exposure
Stop the burning process with water or
saline
Remove smoldering clothing and jewelry
Do not remove STUCK clothing
P
Eye Involvement?
Continuous saline flush in affected eyes.
Flush with water or NS for 10-15 min
Remove jewelry, constricting items, and
expose burned area
Cover burned area with dry sterile dressing
DO NOT USE any ice, lotion, ointment or
antiseptic!
Identify entry and exit sites, apply sterile
dressings
Vascular Access
IVF – NS 500 ml fluid bolus if signs of
hypoperfusion, OR >10% BSA burn
A
present;
If no improvement in patient condition,
administer additional fluid challenges
up to 2000 ml.
P
Cardiac monitor
P
Pain Management
Cardiac monitor
Vascular Access
IVF – NS 500 ml fluid bolus if signs of
hypoperfusion, OR >10% BSA burn
A
present;
If no improvement in patient condition,
administer additional fluid challenges
up to 2000 ml
P
Consider Smoke Inhalation
Transport to UMC Trauma Center for
patients requiring Burn Center evaluation
Burns Protocol
27
Pain Management
History
· Type of exposure (heat, gas, chemical)
· Inhalational injury
· Time of injury
· Past medical history & medications
· Other trauma
· Loss of consciousness
· Tetanus/immunization status
Signs and Symptoms
· Burns, pain, swelling
· Dizziness
· Airway compromise/distress
· Wheezing
· Singed facial or nasal hair
· Hoarseness or voice changes
Differential
· Superficial (1st degree) – red and painful
· Partial Thickness (2nd degree) – blistering
· Full Thickness (3rd degree) – painless/charred
or leathery skin
· Thermal
· Chemical
· Electrical
· Radiation
· Lightning
Pearls
·
·
·
·
·
·
·
·
Burn patients are trauma patients; evaluate for
multisystem trauma.
Assure whatever has caused the burn, is no
longer contacting the injury. (Stop the burning
process!)
Recommended Exam: Mental Status, HEENT,
Neck, Heart, Lungs, Abdomen, Extremities, Back,
Neuro.
Early intubation is required when the patient
experiences significant inhalation injuries.
Potential CO exposure should be treated with
100% oxygen. (For patients in which the primary
event is CO inhalation, transport to a hospital
equipped with a hyperbaric chamber is indicated
[when reasonably accessible].)
Circumferential burns to extremities are
dangerous due to potential vascular compromise
secondary to soft tissue swelling.
Burn patients are prone to hypothermia - never
apply ice or cool burns; must maintain normal
body temperature.
Patients meeting the following Criteria shall be transported to the UMC Burn Center via the Adult or Pediatric Trauma Center:
1. Second and/or third degree burns >20% body surface area (BSA).
2. Second and/or third degree burns >10% body surface area (BSA) in patients under 10 years old or
over 50 years old.
3. Burns that involve the face, hands, feet, genitalia, perineum or major joints.
4. Electrical burns, including lightning injury.
5. Chemical burns.
6. Circumferential burns.
7. Inhalational injury.
Parkland Formula for Fluid Replacement:
4ml x (body wt in kg) x (% BSA burned) = total fluids for 24 hrs
Give ½ in the first 8 hrs; give remainder over next 16 hrs.
Pearls (Electrical)
·
·
·
·
Do not contact the patient until you are certain the source of the electric shock has
been disconnected.
Attempt to locate contact points, (entry wound where the AC source contacted the
patient; an exit at the ground point); both sites will generally be full thickness.
Cardiac monitor; anticipate ventricular or atrial irregularity to include V-Tach, V-Fib,
heart blocks, etc.
Attempt to identify the nature of the electrical source (AC vs DC), the amount of
voltage and the amperage the patient may have been exposed to during the electrical
shock.
Pearls (Chemical)
·
Certainly 0.9% NaCl Sol’n or Sterile Water is preferred;
however if it is not readily available, do not delay; use tap
water for flushing the affected area or other immediate water
sources. Flush the area as soon as possible with the cleanest,
readily available water or saline solution using copious
amounts of fluids.
Burns Protocol
28
Cardiac Arrest (Non-Traumatic)
(Adult CCC CPR)
Refer to Termination of Resuscitation
or DNR/POLST Protocol as appropriate
AT ANY TIME
Return of
Spontaneous
Circulation,
go to Therapeutic
Hypothermia & PostResuscitation Care
Protocol
Meets criteria for Prehospital Death
Determination or DNR/POLST present?
Yes
No
If unwitnessed by EMS
or no CPR in progress
perform 2 min of CCC
If witnessed by EMS or CPR in progress and patient is unresponsive with no
pulse, begin Continuous Chest Compressions (CCC)
Push hard (≥2 Inches) Push fast (≥100/min)
P
VF/VT
P
Defibrillate
E
Continue CPR
for 2 min
A
Vascular Access
Yes
E
Apply AED and defibrillate, if prompted
E
Insert NPA or OPA and begin BVM
at 8 BPM
P
Apply cardiac monitor
Rhythm shockable?
IF HYPOXIA IS THE
CAUSE OF THE ARREST, EARLY
VENTILATION IS
RECOMMENDED
No
P
Asystole/PEA
E
Continue CPR for 2 min
A
Vascular Access
P
EPINEPHRINE
1.0 mg IV/IO q 3-5 min;
ETT Administration
requires 2 to 2.5 times the
dose
Rhythm shockable?
Yes
E
(AED)
P
Defibrillate
E
P
EPINEPHRINE
1.0 mg IV/IO q 3-5 min
ETT Administration
requires 2 to 2.5 times the
dose
A
P
A
Defibrillate if prompted
P
No
Rhythm shockable?
No
Consider
Extraglottic Airway Device
Consider
Rhythm shockable?
Consider
Extraglottic Airway Device
Consider
No
No
E
P
Address H’s & T’s
Rhythm shockable?
Yes
Yes
E
Defibrillate if prompted
(AED)
P
Defibrillate
E
Use Asystole/PEA side as indicated
Check pulse, if organized rhythm
P
AMIODARONE
300 mg IV/IO; may repeat
one dose of 150 mg if
refractory after 5th shock;
If patient remains unresponsive to
resuscitation efforts, consider
Termination of Resuscitation Protocol
Cardiac Arrest (Non-Traumatic) (Adult CCC CPR)
29
Use VF/VT side as
indicated
Yes
History
· Events leading to arrest
· Estimated down time
· Medications
· Existence of terminal illness
Signs and Symptoms
· Unresponsive
· Apneic
· Pulseless
Differential
· Medical vs. Trauma
· VF vs. Pulseless VT
· Asystole
· PEA
· Primary cardiac event vs. respiratory or
drug overdose
Pearls
· For cardiac arrest patients who are pregnant, manual CPR is recommended.
· For cardiac arrest patients who are pregnant, manual displacement of the uterus to the left side is recommended.
.
Left uterine displacement using 1-handed technique.
Terry L. Vanden Hoek et al. Circulation. 2010;122:S829 -S861
Terry L. Vanden Hoek et al. Circulation. 2010;122:S829-S861
Copyright © American Heart Association, Inc. All rights reserved.
Copyright © American Heart Association, Inc. All rights reserved.
·
·
·
·
·
·
·
Efforts should be directed at high quality and continuous compressions with limited interuptions and early
defibrillation when indicated.
Consider early IO placement if IV is difficult.
DO NOT HYPERVENTILATE.
Reassess and document ETT placement using auscultation and ETCO2 capnography.
Switch compressors every two minutes.
Try to maintain patient modesty.
Mechanical chest compression devices should be used if available in order to provide for consistent uninterrupted
chest compressions and crew safety. As noted above, mechanical chest compression devices are not recommended
for the pregnant patient.
H’s & T’s (reversible causes)
· Hypovolemia – Volume infusion
· Hypoxia – Oxygenation & ventilation, CPR
· Hydrogen ion (acidosis) – Ventilation, CPR
· Hypo/Hyperkalemia – Calcium Chloride, Glucose, Sodium Bicarbonate, Albuterol
· Hypothermia - Warming
· Tension pneumothorax – Needle decompression
· Tamponade, cardiac – Volume infusion
· Toxins – Agent specific antidote
· Thrombosis, pulmonary – Volume infusion
· Thrombosis, coronary – Emergent PCI
Cardiac Arrest (Non-Traumatic) (Adult CCC CPR)
30
Chest Pain
12-Lead ECG
P
Non-Specific
Chest Pain
E
Oxygen
Keep SpO2 >94%
A
Consider Vascular
Access
Suspected Aortic
Dissection
E
Vascular Access
A
A
Consider ALBUTEROL for
constricted airways
2.5 mg SVN
P
P
Oxygen
Keep SpO2 >94%
NS 500 ml bolus;
may repeat up to
2000 ml for hypotension
Pain Management
Consider
Pain Management
Chest Pain Protocol
31
Suspected Cardiac
Origin
(Suspected)
History
· Age
· Medications (Viagra/Sildenafil/
Levitra, Cialis/Tadalafil)
· Past medical history (MI, angina,
diabetes, post menopausal)
· Allergies
· Recent physical exertion
· Palliation/Provocation
· Quality (crampy, constant, sharp,
dull, etc.)
· Region/Radiation/Referred
· Time (onset/duration/repetition)
Signs and Symptoms
· CP (pressure, pain, ache, vicelike tightness)
· Location (substernal, epigastric,
arm, jaw, neck, shoulder)
· Pale
· Diaphoresis
· Nausea, vomiting, dizzy
· Time of onset
Differential
· Angina vs. MI
· Pericarditis
· Pulmonary embolism
· Asthma/COPD
· Pneumothorax
· Aortic dissection or aneurysm
· GE reflux or hiatal hernia
· Esophageal spasm
· Chest wall injury or pain
· Pleural pain
· Overdose (cocaine or methamphetamine)
Pearls
· Nitroglycerine is contraindicated for any patient having taken Viagra or similar
medication in the past 24 hours, or 48 hours for Tadalifil, or similar.
· Nitroglycerine is contraindicated in any patient with hypotension, bradycardia or
tachycardia in the absence of heart failure and evidence of a right ventricular
infarction. Caution is advised in patients with inferior wall STEMI and a right sided
ECG should be performed to evaluate right ventricular infarction.
· Diabetics, geriatric and female patients often present with atypical pain or only
generalized complaints (have a low threshold to perform a 12-Lead ECG).
QI Metrics
· 12-Lead ECG completed within 5 minutes of patient contact.
· Pain control documented.
Chest Pain Protocol
32
Childbirth / Labor
Pregnant patient
with signs of
impending delivery
(see pearls)
Normal
Presentation
Puncture amniotic
sac if not already
broken
Deliver and support
the head
Limb Presentation
Breech Presentation
Place patient in left
lateral recumbent
position
Support body of
baby during
delivery of head
Cord Presentation
Position patient on
elbows and knees
with hips elevated
Wrap cord and keep
it moist
Suction mouth, then
nose; if meconium
present, repeat
several times
A
Attempt
Vascular Access
A
Insert gloved hand
to lift baby off cord;
obtain and
document cord
pulse
Attempt
Vascular Access
Deliver upper
shoulder, then
lower shoulder
Deliver remainder
of the baby
A
Clamp and cut
umbilical cord
If multiple births,
repeat steps
Deliver placenta
A
Attempt
Vascular Access
Patient
hypoperfusing?
No
Yes
A
Administer 500 ml NS;
repeat as needed
not to exceed 2,000 ml
Continue General Patient
Care
Transport to
Appropriate Facility
Childbirth / Labor Protocol
33
Attempt
Vascular Access
History
· Due date
· Time contractions started/
duration/frequency
· Rupture of membranes
(meconium)
· Time and amount of any vaginal
bleeding
· Sensation of fetal movement
· Pre-natal care
· Past medical and delivery history
· Medications
· Gravida/Para status
· High risk pregnancy
Signs and Symptoms
· Spasmodic pain
· Vaginal discharge or bleeding
· Crowning or urge to push
· Meconium
Differential
· Abnormal presentation (breech, limb)
· Prolapsed cord
· Placenta previa
· Abruptio placenta
Pearls
· Recommended exam (of mother): Mental Status, Heart, Lungs, Abdomen, Neuro.
· Document all times (delivery, contraction duration and frequency).
· Some bleeding is normal; copious amounts of blood or free bleeding is abnormal.
· Record APGAR at one and five minutes after birth.
· APGAR of 7-10 is normal, while 4-7 requires resuscitative measures.
APGAR
· Activity/Muscle Tone
· Pulse
· Grimace/Reflex Irritability
· Appearance/Skin Color
· Respiration
Score=0
Absent
Absent
No response
Blue-Grey, pale all over
Absent
Score=1
Arms/legs flexed
Below 100
Grimace
Normal, except extremities
Slow, irregular
Childbirth / Labor Protocol
34
Score=2
Active movement
Above 100
Sneeze, cough, pulls away
Normal over entire body
Good, crying
Drowning
No
Airway protected &
ventilation adequate?
Yes
Consider Cervical Stabilization
E
CAVEATS:
1. Adequate ventilation is KEY!!!
2. For patients breathing on their own,
start Oxygen 15L NRB; for patients
not adequately breathing à BVM
3. Do not suction foam in airway, just
bag through it initially.
4. For drowning victims in cardiac
arrest, emphasis should be on good
oxygenation/ventilation à use
traditional 30:2 CPR (no continuous
compressions).
Oxygen 15L NRB
SpO2
P
Capnography
A
ALBUTEROL
2.5 mg in 3.0 ml SVN;
repeat until improvement
P
Consider CPAP
P
Consider 12-Lead ECG
Assessment
Drowning Protocol
35
History
· Submersion in water, regardless
of depth
· Possible history of trauma (dive)
· Duration of immersion
· Temperature of water or
possibility of hypothermia
· Degree of water contamination
Signs and Symptoms
· Unresponsive
· Mental status changes
· Decreased or absent vital signs
· Vomiting
· Coughing, wheezing, rales,
stridor, rhonchi
· Apnea
· Frothy/foamy sputum
Differential
· Trauma
· Pre-existing medical condition
· Barotrauma
· Decompression illness
· Post-immersion syndrome
Pearls
· Recommended Exam: Trauma Survey, Head, Neck, Chest, Abdomen, Back,
Extremities, Skin, Neuro.
· Ensure scene safety.
· Hypothermia is often associated with submersion incidents.
· All patients should be transported for evaluation because of potential for
worsening over the next several hours.
CAVEATS:
1. Adequate ventilation is KEY!!!
2. For patients breathing on their own,
start Oxygen 15L NRB; for patients
not adequately breathing à BVM
3. Do not suction foam in airway, just
4. For drowning victims in cardiac
compressions).
QI Metrics
· Submit the SNHD Submersion Incident Report Form.
Drowning Protocol
36
Hyperkalemia (Suspected)
ALERT!!
This protocol is for
patients with chronic
kidney disease with
suspected
hyperkalemia
Cardiac monitor
P
12-Lead ECG
A
No
ALBUTEROL
2.5 mg in 3.0 ml
continuous SVN
Bradycardia,
Peaked T waves,
Widened QRS, or
Cardiac Arrest
Yes
CALCIUM CHLORIDE
1.0 g slow IVP
Continue to monitor
indicated
P
SODIUM BICARBONATE
1.0 mEq/kg slow IVP
Hyperkalemia (Suspected) Protocol
37
History
· History of renal failure
· History of dialysis
· Trauma, crush injury
Signs and Symptoms
· Cardiac conduction
disturbances
· Irritability
· Abdominal distension
· Nausea
· Diarrhea
· Oliguria
· Weakness
Differential
· Cardiac disease
· Renal failure
· Dialysis
· Trauma
Pearls
· Patients must have suspected hyperkalemia (crush syndrome, chronic renal failure)
AND electrocardiographic findings consistent with hyperkalemia (bradycardia with
widening QRS complexes) AND hemodynamic instability BEFORE initiating treatment.
· Calcium Chloride is contraindicated in patients taking digitalis products.
· Hyperkalemia is defined as a potassium level higher than 5.5 mmol/L.
· Potassium of 5.5 - 6.5 mmol/L - Tall tented T waves.
· Potassium of 6.5 - 7.5 mmol/L - Loss of P waves.
· Potassium of 7.5 - 8.5 mmol/L - Widening QRS.
· Potassium of >8.5 mmol/L - QRS continues to widen, approaching sine wave.
Hyperkalemia (Suspected) Protocol
38
Hyperthermia/Environmental Illness
E
General Adult
Assessment
E
Remove from environment
Temperature measurement
(if available)
Remove tight clothing
Passive cooling measures
Symptom Severity
Heat Exhaustion
Elevated body temp,
cool, moist skin
weakness, anxious tachypnea
Heat Cramps
Normal to elevated body temp,
weakness, muscle cramping
E
E
PO fluids as tolerated
Monitor and reassess
Heat Stroke
High body temp >104,
hot, dry skin
hypotension, AMS/coma
Active cooling measures
Airway as indicated
Vascular Access
A
P
Altered Mental Status
as indicated
NS bolus
500 ml IV/IO;
repeat to effect SBP >90;
max 2L
Cardiac monitor
E
Vascular Access
A
Poor
perfusion?
P
Yes
No
Exit to appropriate
Shock or Trauma
Protocol as indicated
NS bolus
500 ml IV/IO;
max 2L
Cardiac monitor
Poor
perfusion?
Yes
Continue General Patient
Care and Transport
Hyperthermia/Environmental Illness Protocol
39
No
History
· Age, very old and young
· Exposure to increased
temperatures and/or humidity
· Past medical history/medications
· Time and duration of exposure
· Poor PO intake, extreme exertion
· Fatigue and/or muscle cramping
Signs and Symptoms
· AMS/coma
· Hot, dry, or sweaty skin
· Seizures
· Nausea
Differential
· Fever
· Dehydration
· Medications
· Hyperthyroidism
· DTs
· Heat cramps, heat exhaustion, heat stroke
· CNS lesions or tumors
Pearls
· Recommended exam: Mental Status, Skin, Heart, Lung, Abdomen, Extremities, Neuro.
· Extremes of age are more prone to heat emergencies.
· Cocaine, amphetamines, and salicylates may elevate body temperatures.
· Sweating generally disappears as body temperatures rise over 104° F (40° C).
· Intense shivering may occur as patient is cooled.
· Active cooling includes application of cold packs or ice (not directly on skin), fanning
either by air conditioning or fanning.
Heat Cramps
· Consist of benign muscle cramping caused by dehydration and is not associated with an
elevated temperature.
Heat Exhaustion
· Consists of dehydration, salt depletion, dizziness, fever, AMS, headache, cramping,
N/V. Vital signs usually consist of tachycardia, hypotension and elevated temperature.
Heat Stroke
· Consists of dehydration, tachycardia, hypotension, temperature >104° F (40° C), and
AMS.
Hyperthermia/Environmental Illness Protocol
40
Hypothermia/Environmental Illness
E
E
(if available)
Remove wet clothing
Dry/warm patient
Passive warming measures
Hypothermia/Frost
Bite
Localized Cold Injury
E
Systemic Hypothermia
Awake with/without
altered mental status
General wound care
DO NOT rub skin to warm
DO NOT allow refreezing
Respiratory
distress?
Unresponsive
Yes
Respiratory
Distress
No
E
A
P
A
Active warming measures
Yes
Pulse present?
Vascular Access
Cardiac monitor
NS bolus
500 ml IV/IO;
maximum 2L
General Adult Trauma
Assessment
Shock (Non-Trauma)
Continue General Patient Care
and Transport
Hypothermia/Environmental Illness Protocol
41
No
Cardiac Arrest
History
· Age, very young and old
· Exposure to decreased
temperatures, but may occur in
normal temperatures
· Drug or alcohol use
· Infections/sepsis
· Time of exposure/wetness/wind
chill
Signs and Symptoms
· AMS/coma
· Cold, clammy
· Shivering
· Extremity pain
· Bradycardia
Differential
· Sepsis
· Hypoglycemia
· Stroke
· Head injury
· Spinal cord injury
Pearls
· Recommended exam: Mental Status, Heart, Lung, Abdomen, Extremities, Neuro.
· Extremes of age are more prone to cold emergencies.
· Obtain and document patient temperature.
· If temperature is unknown, treat the patient based on suspected temperature.
· Active warming includes hot packs that can be used on the armpit and groin; care
should be taken not to place the packs directly on the skin.
· Warm saline IV may be used.
· Recognize the cardiac arrest resuscitation guidelines for the hypothermic patient.
Hypothermia Categories
· Mild 90°- 95° F (33°- 35° C)
· Moderate 82°- 90° F (28°- 32° C)
· Severe <82 degrees F (<28° C)
Hypothermia Mechanisms
· Radiation
· Convection
· Conduction
· Evaporation
Hypothermia/Environmental Illness Protocol
42
Obstetrical Emergency
Pregnant patient
exhibiting
pre-eclampsia?
Yes
P
MAGNESIUM
SULFATE
2.0 gm in 50 cc NS
over 10 min
P
MAGNESIUM
SULFATE
4.0 gm in 50 cc NS
over 20 min
No
Pregnant patient
exhibiting seizures?
Yes
No
Follow
appropriate
protocol
P
If refractory to
MAGNESIUM
SULFATE, give
MIDAZOLAM
IN/IM/IV/IO;
0.1 mg/kg;
may repeat q 5
at 0.05 mg/kg
IN/IM/IV/IO
Or
DIAZEPAM 5mg IV;
May Repeat q 5 Min
Additional Doses
Require Physician
Order
Transport to
Appropriate
Facility
Obstetrical Emergency Protocol
43
Transport to
Appropriate
Facility
History
· Medical history
· Hypertension medication
· Prenatal care
· Prior pregnancies/births
· Previous pregnancy complications
Signs and Symptoms
· Vaginal bleeding
· Abdominal pain
· Seizures
· Hypertension
· Severe headache
· Visual changes
· Edema of the hands or face
Differential
· Pre-eclampsia/eclampsia
· Placenta previa
· Placenta abruptio
· Spontaneous abortion
Pearls
· Recommended exam: Mental Status, Heart, Lung, Abdomen, Neuro.
· Severe headache, vision changes or RUQ pain may indicate pre-eclapsia.
· In the setting of pregnancy hypertension is defined as >140 systolic or >90 diastolic or a
relative increase of 30 systolic and 20 diastolic from the patient’s normal prepregnancy BP.
· Maintain left lateral position.
· Ask patient to quantify bleeding - number of pads used per hour.
· Any pregnant patient involved in a MVC should be seen by a physician for evaluation.
Obstetrical Emergency Protocol
44
Overdose/Poisoning
E
If ingestion occurred within one hour of EMS arrival,
Administer Activated Charcoal 50 gm PO
A
Extraglottic Airway Device if Indicated
P
Endotracheal Intubation if Indicated
A
Consider Vascular Access
P
Consider Cardiac Monitor
Consider potential cause of
signs/symptoms
Opiate
OD
A
NALOXONE
2.0 mg IN/IM/
IV; may repeat
to a max dose
of 10 mg
Dystonic
Reaction
Cyanide
A
BENADRYL
50 mg IV/IM
P
TCA/ASA
OD
Calcium
Channel
Blocker OD
Beta Blocker
OD
Wide
QRS
Bradycardic
and
hypotensive
Bradycardic
and
hypotensive
1.0 mEq/kg of
8.4% solution
SODIUM
BICARBONATE
IV
CALCIUM
CHLORIDE
1 gm (10%)
slow IV
P
HYDROXOCOBALAMIN
5.0 g IV over 15 min if
available
P
Reassess and Transport as
Appropriate
Overdose/Poisoning Protocol
45
Revised 4/1/2015
GLUCAGON
1.0 mg IM/IV;
may repeat once in 3-5 min
Organophosphate
Toxicity
P
ATROPINE
2.0 mg IV q 15 min
as needed to
decrease secretions
and ventilatory
resistance
History
· Ingestion or suspected ingestion
of a potentially toxic agent
· Substance ingested, route,
quantity
· Time of ingestion
· Reason (suicidal, accidental,
criminal)
· Available medications in home
· Past medical history, medications
Signs and Symptoms
· Hypotension/hypertension
· Decreased respiratory rate
· Tachycardia, dysrhythmias
· Seizures
· SLUDGE
· Malaise, weakness
· GI symptoms
· Dizziness
· Syncope
· Chestpain
Differential
· TCA overdose
· Acetaminophen OD
· Aspirin
· Depressants
· Stimulants
· Anticholinergic
· Cardiac medications
· Solvents, alcohols, cleaning agents,
insecticides
Pearls
· Recommended exam: Mental Status, Skin, HEENT, Heart, Lung, Abdomen, Extremities,
Neuro.
· Overdose or toxin patients with significant ingestion/exposure should be closely
monitored and aggressively treated. Do not hesitate to contact medical control if
needed.
· In the case of cyanide poisoning, altered mental status may be profound. Profound
altered mental status can be defined as a deficit that includes disorientation,
bewilderment and difficulty following commands.
· If patient is suspected to have narcotic overdose/hypoglycemia, administer Narcan/
Glucose prior to exrtraglottic device/intubation.
· Poison Control: 1-800-222-1222
Agents
· Acetaminophen: Initially normal or N/V. Tachypnea and AMS may occur later. Renal
dysfunction, liver failure and/or cerebral edema may manifest.
· Depressants: Decreased HR, BP, temp and RR.
· Anticholinergic: Increased HR, increased temperature, dilated pupils and AMS changes.
· Insecticides: May include S/S of organophosphate poisoning.
· Solvents: N/V, cough, AMS.
· Stimulants: Increased HR, BP, temperature, dilated pupils, seizures, and possible
violence.
· TCA: Decreased mental status, dysrhythmias, seizures, hypotension, coma, death.
Overdose/Poisoning Protocol
46
Revised 4/1/2015
Pain Management
Appropriate treatment protocol
Ketamine 0.2mg/kg
IN/IV/IO
P
No Repeat Dose
E
Comfort measures, i.e. patient
positioning, splinting, ice, etc.
A
Vascular Access
P
Cardiac monitor
MORPHINE 0.1mg/kg
IM/IV; max single dose
10mg
May repeat dose q 10
P
min after the first until
pain relieved or
respiratory depression
occurs
P
P
FENTANYL 1.0 mcg/
kg IN/IM/IV; max
single dose 100 mcg
May repeat dose
after 10 minutes
For nausea/vomiting after
pain medication consider:
ONDANSETRON 4.0 mg ODT/IM/IV
or
DROPERIDOL 1.25 mg IM/IV/IO
Contact Medical Control for additional
doses
Pain Management Protocol
47
HYDROMORPHONE
0.01mg/kg IM/IV;
max single dose
P
1.0mg
May repeat dose
after 10 minutes
History
· Age
· Location, duration
· Severity (1-10)
· Pregnancy status
· Drug allergies and medications
Signs and Symptoms
· Severity (pain scale)
· Quality
· Radiation
· Relation to movement,
respiration
· Increased with palpation of
area
Differential
· Musculoskeletal
· Visceral (abdominal)
· Cardiac
· Pleural, respiratory
· Neurogenic
· Renal (colic)
Pearls
· Recommended exam: Respiratory Status, Mental Status, Area of pain, Neuro.
· Pain severity (1-10) is a vital sign to be recorded before and after medication
administration and patient hand off.
· Monitor BP and respirations closely as sedative and pain control agents may cause
hypotension and/or respiratory depression.
· Consider patient’s age, weight, clinical condition, use of drugs/alcohol, exposure to
opiates when determining initial opiate dosing. Weight based dosing may provide a
standard means of dosing calculation, but it does not predict response.
· Exercise care when administering opiates and benzodiazepines; this combination
results in deeper anesthesia with significant risk of respiratory compromise.
· Burn patients may require more aggressive dosing.
· Administration of Droperidol can result in hypotension, QT prolongation and Torsades
de Pointes.
·
·
·
·
·
QI Metrics
Vital signs with O2 sats recorded.
Pain scale documented before and after intervention.
Vital signs repeated after intervention.
If considering repeat administration of pain medications, nasal cannula capnography
must be utilized.
Pain Management Protocol
48
Pulmonary Edema/CHF
Patient in position of comfort
Airway & ventilation
adequate?
No
Yes
E
A
Vascular Access
P
ETCO2 monitoring
P
Consider CPAP
P
12-Lead ECG
E
BP re-assessment
Hypotensive
SBP <100 mmHg
Normotensive
SBP >100 mmHg
Hypertensive
DBP >100 mmHg
Signs of
cardiogenic shock?
NITROGLYCERIN
0.4 mg SL; may repeat
q 5 min as long as HR >60 and
SYSTOLIC BP >100 mmHg
NITROGLYCERIN
1.6 mg SL;
may repeat q 5 min for
DIASTOLIC BP >100 mmHg
P
Yes
P
DOPAMINE
5-20 mcg/kg/min; titrate to
SYSTOLIC BP >100 mmHg
Pulmonary Edema/CHF Protocol
49
P
History
· Congestive heart failure
· Medications
· Cardiac history
Signs and Symptoms
· Respiratory distress, bilateral
rales
· Apprehension, orthopnea
· JVD
· Pink, frothy sputum
· Peripheral edema
· Diaphoresis
· Hypotension, shock
· Chest pain
Differential
· MI
· Congestive heart failure
· Asthma
· Anaphylaxis
· Aspiration
· COPD
· Pleural effusion
· Pneumonia
· Toxic exposure
Pearls
· Avoid administering Nitroglycerin to any patient who has used Viagra or Levitra in the
past 24 hours, avoid administering nitroglycerin to any patient who has used Cialis in
the past 48 hours.
· Carefully monitor the patient as you administer interventions.
· Consider MI.
· Allow patient to maintain position of comfort.
· Consider dose related effects of Dopamine: 2-10 mcg/kg/min increases myocardial
contractility and HR, improves BP via vasoconstriction; 10-20 mcg/kg/min causes
vasoconstriction of renal, mesenteric, and peripheral blood vessels that can result in
poor perfusion and renal failure.
QI Metrics
· Blood pressure reassessed after each nitroglycerin dose.
· CPAP used appropriately.
· ETCO2 monitored.
Pulmonary Edema/CHF Protocol
50
adequate?
No
Yes
A
Vascular Access
Wheezing or
Bronchospasm
Bilateral Rales or Signs
of Pulmonary Edema
Stridor
Pulmonary Edema/CHF
E
A
ALBUTEROL
assist pt w/own MDI
ALBUTEROL
IPRATROPIUM
P 2.5 ml 0.02% sol’n SVN once; or
DuoNeb 3.0 ml SVN once
P
P
Consider CPAP
Consider
MAGNESIUM SULFATE
2.0 g in 50 ml NS
over 10 min
Respiratory Distress Protocol
51
A
Nebulized
NS SVN
Consider
Allergic Reaction
History
· Asthma, COPD, CHF, chronic
bronchitis, emphysema
· Home treatment (oxygen,
nebulizers)
· Medication
· Toxic exposure
Signs and Symptoms
· Pursed lip breathing
· Decreased ability to speak
· Increased respiratory rate and
effort
· Wheezing, rhonchi
· Use of accessory muscles
· Fever, cough
· Tachycardia
Differential
· Asthma
· Anaphylaxis
· Aspiration
· COPD
· Pleural effusion
· Pneumonia
· Pulmonary embolus
· Pneumothorax
· Cardiac (MI or CHF)
· Hyperventilation
· Inhaled toxin
Pearls
· Recommended exam: Mental Status, HEENT, Skin, Neck, Heart, Lungs, Abdomen,
Extremities, Neuro.
· Pulse oximetry and end tidal continuous waveform capnography must be monitored.
· Consider MI.
· Allow the patient to assume a position of comfort.
Respiratory Distress Protocol
52
Seizure
Patient actively
seizing?
Yes
Patient have a
history of
seizures?
E
No
No
E
Reassess and monitor VS
Yes
E
A
P
No
BG <60 mg/dl?
Vascular Access
Cardiac monitor
Yes
MIDAZOLAM 0.1 mg/kg up to
max 5.0 mg IM/IN/IV; may
repeat dose at 0.05 mg/kg
OR
DIAZEPAM 5.0 mg IM/IV
D10, 1ml/kg IV max
single dose 250ml;
may repeat x 1 in 5 min
A
Yes
BG <60 mg/dl?
GLUCAGON 1.0 mg IM
for no IV access
Persistent (status)
or recurrent
seizure?
No
No
E
Yes
E
A
Glucose test/retest
Vascular Access
Cardiac monitor
P
MIDAZOLAM 0.1 mg/kg up to
max 5.0 mg IM/IN/IV; may
repeat dose at 0.05 mg/kg
OR
DIAZEPAM 5.0 mg IM/IV
Assessment
Seizure Protocol
53 Revised 4/1/2015
History
· Reported or witnessed seizure
activity
· Previous seizure history
· Seizure medications
· History of diabetes
· History of pregnancy
· Time of seizure onset
· Number of seizures
· Alcohol use, abuse, or abrupt
cessation
· Fever
Signs and Symptoms
· Decreased mental status
· Sleepiness
· Incontinence
· Observed seizure activity
· Evidence of trauma
· Unconsciousness
Differential
· CNS trauma
· Tumor
· Metabolic, hepatic or renal failure
· Hypoxia
· Electrolyte abnormality (Na, Ca, Mg)
· Drugs, medication non-compliance
· Infection, fever
· Alcohol withdrawal
· Eclampsia
· Stroke
· Hyperthermia
· Hypothermia
Pearls
· Recommended exam: Mental Status, HEENT, Heart, Lungs, Extremities, Neuro.
· Benzodiazepines are effective in terminating seizures; do not delay IM/IN
administration while initiating an IV.
· Status epilepticus is defined as two or more seizures successively without an
intervening lucid period, or a seizure lasting over five minutes.
· Grand mal seizures (generalized) are associated with loss of consciousness,
incontinence and oral trauma.
· Focal seizures affect only part of the body and are not usually associated with a loss of
consciousness.
· Be prepared to address airway issues and support ventilations as needed.
· Consider ETCO2 monitoring.
Seizure Protocol
54
Shock
E
OxygenIV
Keep
Access
SpO2 >94%
A
Vascular Access
P Cardiac monitor/capnography
Alternative appropriate treatment
protocols as indicated
Non-trauma,
Noncardiogenic
Trauma related
General Trauma
For patients with
known adrenal
insufficiency, administer
patient’s own Solu-Cortef
(hydrocortisone) as
prescribed
Cardiogenic
Appropriate arrhythmia
protocol as indicated
NS bolus 1000 ml;
A may repeat x 1 with
no rales on lung exam
P
Consider DOPAMINE
5-20 mcg/kg/min;
titrate to
SBP >90 mmHg
Shock Protocol
55
P
12-Lead ECG
A
NS bolus 500 ml;
if no rales on lung
exam, may repeat x 1
P
Consider DOPAMINE
5-20 mcg/kg/min;
titrate to
SBP >90 mmHg
History
· Blood loss-vaginal bleeding,
ectopic, GI bleeding or AAA
· Fluid loss-vomiting, diarrhea,
fever
· Infection
· Cardiac tamponade
· Medications
· Allergic reaction
· Pregnancy
· History of poor oral intake
Signs and Symptoms
· Restlessness, confusion
· Weakness, dizziness
· Weak rapid pulse
· Pale, cool, clammy skin
· Delayed capillary refill
· Hypotension
· Coffee-ground emesis
· Tarry stools
Differential
· Hypovolemic shock
· Cardiogenic shock
· Septic shock
· Neurogenic shock
· Anaphylactic shock
· Ectopic pregnancy
· Dysrhythmias
· Pulmonary embolis
· Vasovagal
· Physiologic (pregnancy)
Pearls
· Recommended exam: Mental Status, Skin, Heart, Lungs, Abdomen, Back, Extremities,
Neuro.
· Hypotension can be defined as a systolic BP of <90. This is not always reliable and
should be interpreted in context and patient’s typical BP, if known. Shock may
present with a normal BP initially.
· Shock often is present with normal vital signs and may develop insidiously. Tachycardia
may be the only manifestation.
· Consider all possible causes of shock and treat per appropriate protocol.
Hypovolemic shock
· Hemorrhage, trauma, GI bleeding, ruptured aortic aneurysm, or pregnancy related
bleeding
Cardiogenic shock
· Heart failure, MI, cardiomyopathy, myocardial contusion, toxins
Distributive shock
· Sepsis, anaphylaxis, neurogenic, toxins
Obstructive shock
· Pericardial tamponade, pulmonary embolus, tension pneumothorax
For patients with known adrenal insufficiency, administer patient’s own
Solu-Cortef (hydrocortisone) as prescribed.
Causes of Adrenal Insufficiency:
Addison’s Disease
Congenital Adrenal Hyperplasia
Long term administration of steroids
Others
Shock Protocol
56
Smoke Inhalation
E
Oxygen 100% NRB
P
A
Cardiac monitor
Vascular Access
NS bolus 500 ml up to max
2000 ml for hypoperfusion
Other treatment protocols (Burns)
as indicated
Yes
P
HYDROXOCOBALAMIN
5.0 g IV over 15 min
Cardiac arrest or
hypotension or
profound altered
mental status?
No
Transport to UMC Trauma
Smoke Inhalation Protocol
57
Revised 4/1/2015
History
· Exposed to smoke in a structure
fire
· Exposed to smoke in a vehicle fire
· Exposed to smoke from other
sources, industrial, confined
space, wilderness fire, etc.
Signs and Symptoms
· Facial burns
· Singed nasal hairs or facial hair
· Facial edema
· Stridor
· Grunting respirations
Differential
· COPD
· CHF
· Toxic inhalation injury
· Caustic inhalation injury
Pearls
· Protect yourself and your crew.
· Have a high index of suspicion when treating patients at the scene of a fire.
· If the medication is not available on scene do not delay transport waiting for it.
· Carefully monitor respiratory effort and correct life threats immediately.
· Decide early on if you want to intubate as burned airways swell, making intubation
difficult.
· Profound altered mental status can be defined as a deficit that includes disorientation,
Preparation and Administration of Hydroxocobalamin
Complete Starting Dose: 5 g
1. Reconstitute: Place the vial in an upright position.
Add 200 mL of 0.9% Sodium Chloride Injection* to the vial using the
transfer spike. Fill to the line.
* 0.9% Sodium Chloride Injection is the recommended diluent
(diluent not included in the kit). Lactated Ringer's Solution and 5%
Dextrose Injection have also been found to be compatible with
Hydroxocobalamin.
2. Mix: The vial should be repeatedly inverted or rocked, NOT shaken,
for at least 60 seconds prior to infusion.
3. Infuse Vial: Use vented intravenous tubing, hang and infuse over
15 minutes.
Smoke Inhalation Protocol
58
Revised 4/1/2015
Stroke (CVA)
P
Cardiac monitor
12-Lead ECG
E
A
Vascular Access
E
Document:
1. Last known normal (onset)
2. Witness with phone number
Perform and document Cincinnati
Stroke Scale (CSS)
Yes
If symptom onset <6hrs
à rapid transport to
approved Stroke Center*
Radio Contact with
Receiving Facility
Findings suggestive of
a stroke based on
CSS?
*Approved Stroke Centers
Centennial Hills
Desert Springs
MountainView
Southern Hills
Spring Valley
St. Rose San Martin
St. Rose De Lima
St. Rose Siena
Summerlin
Sunrise
UMC
Valley
Stroke (CVA) Protocol
59
No
Other treatment
History
· Previous CVA, TIAs
· Previous cardiac/vascular surgery
· Associated diseases: diabetes,
HTN, CAD
· Atrial fibrillation
· Medications
Signs and Symptoms
· AMS
· Weakness, paralysis
· Blindness or other sensory loss
· Aphasia, dysarthria
· Syncope
· Vertigo, dizziness
· Vomiting
· Headache
· Seizures
· Respiratory pattern change
· Hypertension, hypotension
Differential
· AMS
· TIA
· Seizure
· Hypoglycemia
· Tumor
· Trauma
· Dialysis/renal failure
Pearls
· Recommended exam: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities,
Neuro.
· Determine time of onset of symptoms or last time patient was seen normal.
· Transport to a Stroke Center.
Stroke centers
· Centennial Hills
· Desert Springs
· MountainView
· Southern Hills
· Spring Valley
· St. Rose de Lima
· St. Rose San Martin
· St. Rose Siena
· Summerlin
· Sunrise
· UMC
· Valley
QI Metrics
· Cincinnati Stroke Scale
completed.
· Time of symptom
onset documented.
· Blood glucose
documented.
· 12 lead ECG
completed.
· Scene time <10 min.
Facial Droop
· Normal: Both sides of face move equally
· Abnormal: One side of face does not move at all
QI Metrics:
1. Cincinnati Stroke
Scale and time of
symptom onset
documented
2. Blood Glucose
documented
3. 12-Lead ECG done
4. Scene time <10 min
Arm Drift
· Normal: Both arms move equally well, or not at all.
· Abnormal: One arm drifts compared to the other.
Speech
· Normal: Uses correct words without slurring.
· Abnormal: No speech, or slurred or inappropriate words.
Stroke (CVA) Protocol
60
Tachycardia / Stable
(Normal Mental Status, Palpable Radial Pulse)
P
A
P
Narrow Complex
≤0.11 Sec
P
Vagal Maneuvers
Successful?
Cardiac monitor
Wide Complex
≥0.12 Sec
Vascular Access
12-Lead ECG
Undifferentiated
Monomorphic VT
Suspected to be SVT with
Aberrancy
Yes
P
Regular Monomorphic VT
Torsades de Pointes
AMIODARONE
150 mg in 50 cc NS
over 10 min
MAGNESIUM SULFATE
2.0 gm IV in 50 cc NS
over 10 min
P
NO
P
Administer
ADENOSINE
6 mg rapid IVP
Successful?
Successful?
Yes
P
Successful?
No
No
Administer
ADENOSINE
12 mg rapid IVP
Yes
P
Sychronized
Cardioversion
Consider sedation:
ETOMIDATE
0.15 mg/kg IV
Tachycardia / Stable Protocol
61
No
P
Defibrillation
Consider sedation:
ETOMIDATE
0.15 mg/kg IV
History
· Medications (aminophylline, diet
pills, thyroid supplements,
decongestants, digoxin)
· Diet (caffeine)
· Drugs (cocaine,
methamphetamines)
· Syncope/near syncope
· History of palpitations/racing
heart
Signs and Symptoms
· Heart rate >150
· Dizziness, CP, SOB
· Diaphoresis
· CHF
Differential
· Heart disease (WPW, valvular)
· Sick sinus syndrome
· MI
· Electrolyte imbalance
· Exertion, fever, pain, emotional stress
· Hypoxia
· Hypovolemia
· Drug effect, overdose
· Hyperthyroidism
Pearls
Neuro.
· Carefully monitor patients as you treat them; stable tachycardia may convert to
unstable rhythms/conditions quickly.
· Sedate patients prior to cardioversion, if time allows.
Tachycardia / Stable Protocol
62
Tachycardia / Unstable
(Mental Status Changes, No Palpable Radial Pulse)
Narrow Complex
≤0.11 Sec
P
Cardiac monitor
A
Vascular Access
Wide Complex
≥0.12 Sec
Torsades de
Pointes
P
If IV established,
administer
Adenosine
12 mg rapid IVP
Monomorphic VT
Defibrillate
P
P Consider sedation:
Rhythm change?
ETOMIDATE
.15 mg/kg IV
Yes
Rhythm
change?
Sychronized
Cardioversion
Consider sedation:
ETOMIDATE
.15 mg/kg IV
Rhythm
change?
Yes
No
P
Rhythm change?
MAGNESIUM
SULFATE
P
2.0 gm IV in 50 cc NS
over 10 min
Rhythm
change?
Yes
Rhythm
change?
Transport
No
P
Yes
Repeat Sychronized
Cardioversion or
defibrillate if VT not
resolved; assess need
for repeat sedation
Rhythm
change?
Yes
No
No
AMIODARONE
150 mg in 50 cc NS
over 10 min
Rhythm
change?
Yes
Repeat
defibrillation; assess
need for repeat
P
sedation
Repeat Sychronized
Cardioversion; assess
need for repeat
sedation
Rhythm change?
P
No
No
P
No
No
Sychronized
Cardioversion
Consider sedation:
ETOMIDATE
0.15 mg/kg IV
Continue
General
Adult
Assessment
Continue
General Adult
Assessment
No
Transport
Transport
Tachycardia / Unstable Protocol
63
History
· Medications (aminophylline, diet
pills, thyroid supplements,
decongestants, digoxin)
· Diet (caffeine)
· Drugs (cocaine,
methamphetamines)
heart
Signs and Symptoms
· Cardiac arrest
· Heart rate >150
· Diaphoresis
· CHF
Differential
· MI
· Hypoxia
· Hypovolemia
· Hyperthyroidism
Pearls
Neuro.
· If patient is in arrest, efforts should focus on quality chest compressions and rhythm
correction.
· Administer Adenosine at a proximal IV site, rapidly followed by a saline flush.
Tachycardia / Unstable Protocol
64
Target Temperature Management & Post-Resusci
P
12-Lead ECG
ROSC w/patient
unresponsive to
voice or pain?
Yes
Patient meets following criteria:
1. >18 years of age
2. Temp S/P ROSC >34° C (93° F)
3. No purposeful response to
voice or pain
4. BG >60
5. Sustained ETCO2 waveform monitoring
in place
6. Cardiac arrest not due to trauma
7. Not pregnant
No
No
Other appropriate treatment
Yes
P
Cardiac monitor, SPO2, ETCO2
A
Vascular Access x 2
E
Neuro exam
E
A
* Approved Hypothermia Centers:
Centennial Hills
Desert Springs
MountainView Hospital
St. Rose De Lima
St. Rose Siena
Southern Hills
Spring Valley
Summerlin
Sunrise
UMC
Valley
Expose patient;
Ice packs to axilla and groin
COLD NS, 250 ml/hr
Up to 1L
Maintain ETCO2 at approx 40 mmHG;
DO NOT HYPERVENTILATE
p
DOPAMINE 5-20 mcg/kg/min PRN;
Titrate to keep SBP >90mmHg
Other treatment protocols
as indicated
Transport patient to approved
Hypothermia Center*
Therapeutic Hypothermia & Post-Resuscitation Care
65
History
· Non-traumatic cardiac arrest
· Any presenting ECG rhythm
Signs and Symptoms
· Cardiac arrest
· Return of spontaneous
circulation post cardiac arrest
Differential
· Continue to address rhythm specific
differentials
Pearls
· Hyperventilation is to avoided in any cardiac arrest/post arrest resuscitation.
· Initial ETCO2 may be elevated immediately post resuscitation but will normalize.
· Transport to a hypothermia center as listed is required for continued management of
the post arrest patient.
Therapeutic Hypothermia & Post-Resuscitation Care
66
Use supplemental
oxygen to maintain
an oxygen saturation
of >94%
or >90% for patients
on home oxygen for
chronic conditions
E
Basic Airway Maneuvers
-Open Airway Chin Lift/Jaw Thrust
-NPA or OPA as needed
-Suction as needed
Respiratory Distress and/or
Tracheostomy Tube
Replacement Protocol
if needed
Consider Altered Mental Status/Syncope
Administer oxygen
E
BVM as needed
Intervention
effective?
No
Yes
Extraglottic Airway
A
ECG Monitor
For Nasotracheal Intubation Prep the Nostrils With
PHENLEPHRINE 1-2 Sprays Each, and LIDOCAINE 2% Lubricant
Consider Sedation Administer ETOMIDATE 0.3 mg/kg IV Or; KETAMINE 2 mg/kg IV Or 4 mg/kg IM
P
Maintain Sedation Administer MIDAZOLAM 0.1 mg/kg IV/IN/IM;
May Repeat q 5 Minutes at 0.05 mg/kg IV/IN/IM Or;
DIAZEPAM 5 mg IV; May Repeat Dose after 5 Minutes With Physician Order
Yes
Extraglottic/ETT
placement successful?
No
Able to ventilate
without extraglottic/
ETT in place?
Yes
No
P
Continue Care
and Transport as
Appropriate
Cricothyroidotomy
Ventilation Management Protocol
67
Always weigh the risks and benefits of endotracheal intubation in the field against transport. All prehospital
endotracheal intubations are considered high risk. If ventilation/oxygenation is adequate, transport may be the best
option. The most important airway device and the most difficult to use correctly and effectively is the Bag Valve Mask
(not the laryngoscope). Few prehospital airway emergencies cannot be temporized or managed with proper BVM
techniques.
DIFFICULT AIRWAY ASSESSMENT:
Difficult BVM Ventilation-MOANS: Difficult Mask seal due to facial hair, anatomy, blood or secretions/trauma; Obese
or late pregnancy; Age >55; No teeth (roll gauze and place between gums and cheeks to improve seal); Stiff or
increased airway pressures (asthma, COPD, obese, pregnant).
Difficult Laryngoscopy-LEMON: Look externally for anatomical distortions (small mandible, short neck, large tongue);
Evaluate 3-3-2 Rule (Mouth open should accommodate 3 patient fingers, mandible to neck junction should
accommodate 3 patient fingers, chin-neck junction to thyroid prominence should accommodate 2 patient fingers);
Mallampati (difficult to assess in the field); Obstruction / Obese or late pregnancy; Neck mobility.
Difficult Extraglottic Device Placement-RODS: Restricted mouth opening; Obstruction / Obese or late pregnancy;
Distorted or disrupted airway; Stiff or increased airway pressures (asthma, COPD, obese, pregnant).
Nasotracheal intubation: Orotracheal intubation is the preferred choice. Procedure requires patient to have
spontaneous breathing. Contraindicated in anatomically disrupted or distorted airways, increased intracranial
pressure, severe facial trauma, basal skull fracture, head injury.
Pearls
· Capnometry (Color) or capnography is mandatory with all methods of intubation. Document results.
· Continuous capnography (ETCO2) is mandatory for the monitoring of all patients with an ET tube.
· If an effective airway is being maintained by BVM and/or basic airway adjuncts (e.g. nasopharyngeal airway)
with continuous pulse oximetry values of ≥90% or values expected based on pathophysiologic condition
with otherwise reassuring vital signs (e.g. pulse oximetry of 85% with otherwise normal vitals in a post-drowning
patient), it is acceptable to continue with basic airway measures instead of using an extraglottic airway device or
intubation. Consider CPAP as indicated by protocol and patient condition.
· For the purposes of this protocol, a secure airway is achieved when the patient is receiving appropriate
oxygenation and ventilation.
· An intubation attempt is defined as passing the laryngoscope blade or endotracheal tube past the teeth or
inserted into the nasal passage.
· An appropriate ventilatory rate is one that maintains an ETCO2 of 35 - 45. Avoid hyperventilation.
· Paramedics should use an extraglottic airway device if oral-tracheal intubation is unsuccessful.
· Maintain C-spine stabilization for patients with suspected spinal injury.
· Cricoid pressure and BURP maneuver may assist with difficult intubations. They may worsen view in some cases.
· Gastric tube placement should be considered in all intubated patients, if time allows.
· It is important to secure the endotracheal tube well.
Ventilation Management Protocol
68
PEDIATRIC
TREATMENT
PROTOCOLS
69
General Pediatric Assessment
Scene Safety / Scene Size-Up
Nature of Call / Mechanism of Injury
PPE / BSI
Bring all equipment to patient’s side,
including Broselow Tape
S.T.A.R.T. Triage
Unresponsive
Level of Consciousness
None or <60
Check Pulse
Signs of compromise or not protecting
Airway
Inadequate or respiratory distress
Breathing
Altered or confused
Disability
Hemorrhage Control
Tourniquet
Syncope
Bleeding
Circulation
Cardiac Arrest
History – HPI & AMPLE
Vital Signs & Physical Exam
E
Blood glucose testing as indicated
Specific treatment protocol as indicated
Cervical Stabilization as indicated
Comfort measures (splint, position of comfort)
P
Cardiac monitor as indicated
A
Vascular Access as indicated
Oxygen therapy to keep SpO2 >94%
P
Pain Management as indicated
Radio Contact for all pediatric patients.
Transport to closest facility for:
- Airway emergencies (unable to
oxygenate/ventilate)
Transport per Pediatric Destination Criteria
General Pediatric Assessment Protocol
70
Pearls
· For all scenes where patient needs exceed available EMS resources, initial
assessment and treatment shall be in accordance with an approved triage
methodology.
· Correct life-threatening problems as identified.
· If the ability to adequately ventilate a patient cannot be established, the patient
must be transported to the nearest emergency department.
· Never withhold oxygen from a patient in respiratory distress.
· Contact with online medical control should be established by radio. Telephone
contact may only be used if the call is routed via a recorded phone patch through
the FAO at 702-382-9007.
Disposition
· Patients sustaining traumatic injuries shall be transported in accordance with the Trauma Field Triage Criteria Protocol.
· Patients sustaining burn injuries shall be transported in accordance with the Burns Protocol.
· Pediatric patients (<18 y/o for transport purposes only) shall be transported in accordance with the Pediatric
Destination Protocol.
· Patients with evidence of a stroke shall be transported in accordance with the Stroke Protocol.
· Sexual assault victims <13 y/o shall be transported to Sunrise Hospital.
· Sexual assault victims 13 y/o up to 18 y/o shall be transported to Sunrise Hospital or UMC.
· Sexual assault victims 18 y/o and older shall be transported to UMC.
· For sexual assault victims outside a 50-mile radius from the above facilities, the patient shall be transported to the
nearest appropriate facility.
· Stable patients shall be transported to the hospital of their choice; if the patient has no preference, the patient should
be transported to the closest facility.
Internal Disaster
· If a hospital declares an internal disaster, that facility is to be bypassed for all patients except patients in cardiac arrest,
or in whom the ability to adequately ventilate has not been established.
· Operational exceptions may be initiated in regard to transport to hospitals on internal disaster.
General Pediatric Assessment Protocol
71
General Pediatric Trauma Assessment
GCS <8
E
BVM if O2 sat ≤94%
E
Palpable
radial pulse?
No
A
GCS >8
Glasgow Coma
Score
Yes
A
Vascular Access
Vascular Access
NS 20 ml/kg bolus
B
Secondary Survey
Suspected tension pneumothorax
P
Sucking chest wound
E
Control active hemorrhage
E
Obvious fractures
E
Suspected traumatic brain injury
E
P
P
Open wounds
E
E
P
Needle
Needle
Thoracentesis
Thoracentesis
Apply 3-sided occlusive
Apply 3-sided occlusive dressing
dressing
Hemorrhage Control
Tourniquet
Immobilize
Immobilizefractures,
fractures;assess
assess distal
distal pulse
pulse
Head
bed of
30 bed
degrees
&
RaiseofHead
30 degrees
&
Capnography–ETCO
2 35 2mmHg
Capnography–ETCO
35mmHg
Cover with gauze; wet trauma
dressing
forgauze;
abdominal
Cover with
wet trauma
dressingevisceration
for abdominal evisceration
Pain Management
Transport & Radio Contact to
appropriate trauma center
based on TFTC
General Pediatric Trauma Assessment Protocol
72
History
· Time and mechanism of injury
· Damage to structure or vehicle
· Location in structure or vehicle
· Others injured or dead
· Speed and details of MVC
· Restraints/protective equipment
· Medications
Signs and Symptoms
· Pain, Swelling
· Deformity, lesions, bleeding
· AMS or unconscious
· Arrest
Differential (Life threatening)
· Flail chest
· Open chest would
· Hemothorax
· Intra-abdominal bleeding
· Pelvis/femur fracture
· Spine fracture/cord injury
· Head injury
· Extremity fracture
· HEENT (airway obstruction)
· Hypothermia
Pearls
· Recommended exam: Mental Status, Skin, HEENT, Heart Lung, Abdomen,
Extremities, Back, Neuro.
· Transport destination is based on the Trauma Field Triage Criteria Protocol.
· Transport should not be delayed for procedures; ideally procedures should be
performed enroute when possible.
· BVM is an acceptable method of ventilating and managing an airway if pulse
oximetery can be maintained ≥90%.
· Pediatric patients should be evaluated with a high index of suspicion; occult injuries
may be present and pediatric patients can decompensate quickly.
General Pediatric Trauma Assessment Protocol
73
Pediatric Abdominal Pain, Nausea & Vomiting
Hypovolemia or witnessed vomiting?
Yes
No
Subjective
nausea or
vomiting?
A
Vascular Access
NS 20 ml/kg IV;
may repeat up to 60 ml/kg
Yes
P
P
ONDANSETRON
0.15 mg/kg ODT/IM/IV
up to max dose 4.0 mg**
ONDANSETRON
No
Reassess
Transport to Pediatric Facility
**Round up to nearest ½
pill
Pediatric Abdominal Pain, Nausea & Vomiting Protocol
74
History
· Age
· Medical/surgical history
· Onset
· Quality
· Severity
· Fever
Signs and Symptoms
· Pain location
· Tenderness
· Nausea
· Vomiting
· Diarrhea
· Dysuria
· Constipation
Differential
· Liver (Hepatitis)
· Gastritis
· Pancreatitis
· Kidney stone
· Appendicitis
· Bladder
· Bowel obstruction
· Gastroenteritis
Pearls
·
·
·
·
·
·
·
·
Recommended Exam: Mental Status, Skin, HEENT, Heart, Lung, Abdomen, Back,
Extremities, Neuro.
Document mental status and vital signs prior to administration of anti-emetics & pain
management.
Repeat vital signs after each fluid bolus.
Consider retroperitoneal palpation for kidney pain.
Pediatric fluid bolus is 20 ml/kg; may repeat to a maximum of 60 ml/kg.
If there is suspicion that the patient is in DKA, do not exceed 20 ml/kg NS.
Morphine is not recommended in children for abdominal pain.
Consider cardiac and ETCO2 monitoring.
Pediatric Abdominal Pain, Nausea & Vomiting Protocol
75
Pediatric Allergic Reaction
Evidence of airway
involvement/breathing
difficulties?
No
Yes
A
A
EPINEPHRINE
Vascular Access
Diphenhydramine
1.0 mg/kg IM/IV;
max 50 mg
E
Assist patient with own autoinjector
A
Epinephrine 1:1000,
0.01 mg/kg IM;
max single dose 0.3 mg;
may repeat q 15 min
up to max 0.9 mg
Reassess patient q 5 min
Yes
Patient in shock?
No
ALBUTEROL
E
Assist patient with MDI
A
ALBUTEROL 2.5 mg SVN;
repeat as needed
A 2.5 mg SVN; repeat as needed
P
Cardiac monitor
A
IV access
20 ml/kg NS bolus;
A
DIPHENHYDRAMINE
1.0 mg/kg IM/IV;
max 50 mg
Continue General Pediatric Assessment
Pediatric Allergic Reaction Protocol
76
P
Cardiac monitor
A
IV access
20 ml/kg NS bolus;
A
DIPHENHYDRAMINE
1.0 mg/kg IM/IV;
max 50 mg
P
EPINEPHRINE
1:10,000
0.01 mg/kg IV/IO
History
· Onset and location
· Insect sting or bite
· Food allergy/exposure
· Medication allergy/exposure
· New clothing, soap, detergent
· Past history of reactions
· Medication history
Signs and Symptoms
· Itching or hives
· Coughing/wheezing or
respiratory distress
· Throat or chest constriction
· Difficulty swallowing
· Edema
· Nausea/vomiting
Differential
· Urticarial (rash only)
· Anaphylaxis (systemic effect)
· Shock (vascular effect)
· Angioedema (drug induced)
· Aspiration/airway obstruction
· Asthma/COPD
· CHF
Pearls
·
·
·
·
·
Recommended Exam: Mental Status, Skin, Heart, Lung.
Anaphylaxis is an acute and potentially lethal multisystem allergic reaction.
Epinephrine is a first-line drug that should be administered in acute anaphylaxis (moderate/
severe symptoms). IM Epinephrine (1:1,000) should be administered in priority before or
during attempts at IV or IO access.
Anaphylaxis refractory to repeat doses of IM Epinephrine may require IV Epinephrine
(1:10,000) administration by IV push or Epinephrine infusion.
Contact Medical Control for refractory anaphylaxis.
Severity
·
·
·
Mild reactions involve skin rashes, itchy sensation or hives with no respiratory involvement.
Moderate reactions involve skin disorders and may include some respiratory involvement
like wheezing, yet the patient still maintains good tidal volume air exchange.
Severe reactions involve skin disorders, respiratory difficulty, and may include hypotension.
Special Considerations
·
·
·
Always perform ECG monitoring when administering Epinephrine.
Consider Dopamine for hypotension refractory to administration of Epinephrine.
Provide oxygen and airway support as needed.
QI Metrics
·
·
Epinephrine given appropriately.
Airway assessment documented.
Pediatric Allergic Reaction Protocol
77
Pediatric Altered Mental Status
BG <60 mg/dl
BG <40 mg/dl in
newborn
E
E
A
Vascular Access
No
ORAL GLUCOSE
if patient protecting airway
BG >60 mg/dl
P
Cardiac monitor
12-Lead ECG
D10, 5ml/kg IV
max single dose 25 gm
A
Consider NS 20 ml/kg IV;
may repeat up to 60 ml/kg;
A
if BG >250, then 10 ml/kg
bolus
GLUCAGON 0.5 mg IM (<20 kg);
1.0 mg IM (>20 kg) for no IV access
Improved mental
status?
Yes
indicated
If unresponsive, with
respiratory depression &
suspected narcotic overdose
Treat hypoglycemia and
suspected narcotic overdose
before using advanced
airways!!
No
Consider the
Following:
Evidence of a seizure of
post-ictal state?
Seizure
Signs of hypoperfusion?
Shock
Signs of trauma or head
injury?
General Trauma
NALOXONE 0.1 mg/kg
IN/IM/IV; may repeat if patient
A slow to respond; titrate to effect;
max single dose 2.0 mg;
total dose 10 mg
Pediatric Altered Mental Status Protocol
78
Revised 6/03/2015
Overdose/Poisoning
History
· Medications
· Recent illness
· Irritability
· Lethargy
· Changes in feeding/sleeping
· Diabetes
· Potential ingestion
· Trauma
Signs and Symptoms
·
·
·
·
·
·
·
Differential
Decrease in mentation
Change in baseline mentation
Decrease in blood sugar
Cool, diaphoretic skin
Increase in blood sugar
Warm, dry, skin; fruity breath
Kussmaul respirations, signs of
dehydration
· Hypoxia
· CNS (trauma, stroke, seizure, infection)
· Thyroid (hyper/hypo)
· Shock (septic-infection, metabolic, traumatic)
· Diabetes (hyper/hypoglycemia)
· Toxicological
· Acidosis/Alkalosis
· Electrolyte abnormalities
· Psychiatric disorder
Pearls
·
·
·
·
·
·
Recommended Exam: Mental Status, HEENT, Skin, Heart, Lung, Abdomen, Back, Extremities
and Neuro.
Pay careful attention to the head exam for signs of injury.
Be aware of AMS as presenting sign of an environmental toxin or Haz-Mat exposure and
protect personal safety and that of other responders.
Consider alcohol, prescription drugs, illicit drugs and over the counter preparations as
possible etiology.
If narcotic overdose or hypoglycemia is suspected, administer Narcan or Glucose prior to
advanced airway procedures.
Narcan is not recommended in the newly born.
Pediatric Altered Mental Status Protocol
79
Pediatric Behavioral Emergency
Scene Safety
Protocol for pediatric
patients <12 yrs old
Consider medical causes for the
patient’s behavior:
1. Hypoxia
2. Intoxication / Overdose
3. Hypoglycemia / Electrolytes
4. Head Injury
5. Post-ictal State
Implement the
S.A.F.E.R. model
Threatened or acted in a way that
suggests threat to self or others
Yes
No
Transport to a Pediatric Facility as
appropriate
Consider Benzodiazepine IM
2-point restraints; consider law
enforcement escort; or 4-point
restraints if needed
Transport to a Pediatric Facility
Pediatric Behavioral Emergency Protocol
80
History
· Situational crisis
· Psychiatric illness/medications
· Injury to self or threat to others
· Medic Alert tag
· Substance abuse/overdose
· Diabetes
Signs and Symptoms
· Anxiety, agitation, confusion
· Affect change, hallucinations
· Delusional thoughts, bizarre
behavior
· Combative, violent
· Expression of suicidal/
homicidal thoughts
Differential
· Altered mental status differential
· Alcohol intoxication
· Toxin/substance abuse
· Withdrawal syndromes
· Depression
· Bipolar
· Schizophrenia
· Anxiety disorder
Pearls
·
·
·
·
·
·
·
·
Midazolam is NOT recommended for use in children for behavioral emergencies.
Law enforcement assistance should be requested on all calls involving potentially
violent patients.
Under no circumstances are patients to be transported restrained in the prone
position.
Recommended Exam: Mental Status, Skin, Heart, Lung, Neuro.
Consider all possible medical/trauma causes for behavior.
Do not irritate the patient with a prolonged exam.
EMS providers are mandatory reporters in regard to suspected abuse of any
vulnerable person.
Consider cardiac and ETCO2 monitoring.
Dystonic Reaction
·
·
·
Condition causing involuntary muscle movements or spasms typically of the face, neck and
upper extremities.
Typically an adverse reaction to drugs such as Haloperidol (may occur with administration).
When recognized, administer Diphenhydramine 1 mg/kg up to 50 mg IM/IV.
Pediatric Behavioral Emergency Protocol
81
Pediatric Bradycardia
Bradycardia
causing
hypotension,
altered mental
status, poor
perfusion or
shock?
No
Identify underlying cause
E
A
P
Yes
Identify underlying cause
Cardiac monitor
Consider
Overdose/Poisoning
Monitor, Reassess, Transport to
Pediatric Facility
E
A
Vascular Access
P
Cardiac monitor
HR <60
bpm?
Yes
No
E
CPR
P
EPINEPHRINE
1:10,000 0.01 mg/kg IV/IO
1:1000 0.1 mg via ETT (max
1.0 mg); repeat
q 3-5 min
P
Cardiac Arrest
ATROPINE
0.02 mg/kg IV/IO (min dose
0.1 mg; max 0.5 mg)
may repeat once after 5 min
Pulseless
A
NS bolus 20 ml/kg;
P
EPINEPHRINE
1:10,000 0.01 mg/kg IV/IO
1:1000 0.1 mg via ETT (max
1.0 mg); repeat
q 3-5 min
P
ATROPINE
0.02 mg/kg IV/IO (min dose
0.1 mg, max 0.5 mg);
Consider Transcutaneous
Pacing
Reassess
Pediatric Bradycardia Protocol
82
History
· Respiratory insufficiency
· Medications
· Pacemaker
Signs and Symptoms
· HR <60/min with hypotension,
acute altered mental status,
chest pain, acute CHF, seizures,
syncope, or shock secondary to
bradycardia
· Respiratory distress
Differential
· Hypoxia
· Hypothermia
· Sinus bradycardia
· Athletic
· Head injury (elevated ICP)
· Spinal cord lesion
· Overdose
Pearls
· Pediatric pacing is by Telemetry Physician order only.
· Recommended Exam: Mental Status, HEENT, Heart, Lung, Neuro.
· Bradycardia causing symptoms is typically <50/minute. Rhythm should be
interpreted in the context of symptoms and pharmacological treatment given only
when symptomatic; otherwise, monitor and reassess.
· Identifying signs and symptoms of poor perfusion caused by bradycardia are
paramount.
· Hypoxemia is a common cause of bradycardia; be sure to oxygenate the patient
and provide ventilatory support as needed.
Pediatric Bradycardia Protocol
83
Pediatric Burns
Thermal Exposure
Chemical/Electrical Exposure
Stop the burning process with water or saline
Remove smoldering clothing and jewelry
Do not remove STUCK clothing
P
Protect from
hypothermia!
Cardiac monitor
Eye Involvement?
Continuous saline flush in affected eyes.
Flush with water or NS for 10-15 min
Remove jewelry, constricting items, and
expose burned area
Cover burned area with dry sterile dressing
DO NOT USE any ice, lotion, ointment or
antiseptic!
Identify entry and exit sites,
apply sterile dressings
Vascular Access
Vascular Access
IVF – NS 20 ml/kg fluid bolus if signs
of hypoperfusion, OR >10% BSA
A
burn present.
If no improvement in patient
condition, administer additional
fluid challenges up to 60 ml/kg.
P
Cardiac monitor
P
Pain Management
IVF – NS 20 ml/kg fluid bolus if signs
of hypoperfusion, OR >10% BSA
A
burn present.
If no improvement in patient
condition, administer additional
fluid challenges up to 60 ml/kg.
P
Consider Smoke Inhalation
Transport to UMC Pediatric ED for
patients requiring Burn Center evaluation
Pediatric Burns Protocol
84
Pain Management
History
· Type of exposure (heat, gas, chemical)
· Inhalational injury
· Time of injury
· Past medical history & medications
· Other trauma
· Tetanus/immunization status
Signs and Symptoms
· Burns, pain, swelling
· Dizziness
· Airway compromise/distress
· Wheezing
· Singed facial or nasal hair
· Hoarseness or voice changes
Differential
· Superficial (1st degree) – red and painful
· Partial Thickness (2nd degree) – blistering
· Full Thickness (3rd degree) – painless/charred
or leathery skin
· Thermal
· Chemical
· Electrical
· Radiation
· Lightning
Pearls
·
·
·
·
·
·
·
·
·
Burn patients are Trauma Patients; evaluate
for multisystem trauma.
Assure whatever has caused the burn, is no
longer contacting the injury. (Stop the
burning process!)
Recommended Exam: Mental Status, HEENT,
Neck, Heart, Lungs, Abdomen, Extremities,
Back, Neuro.
Early intubation is required when the patient
experiences significant inhalation injuries.
Potential CO exposure should be treated
with 100% oxygen. (For patients in which the
primary event is CO inhalation, transport to a
hospital equipped with a hyperbaric chamber
is indicated [when reasonably accessible].)
Circumferential burns to extremities are
dangerous due to potential vascular
compromise secondary to soft tissue
swelling.
Burn patients are prone to hypothermia never apply ice or cool burns; must maintain
normal body temperature.
Evaluate the possibility of child abuse with
children and burn injuries.
Patients meeting the following criteria shall be transported to the UMC Burn Center via the Adult or Pediatric Trauma Center:
1. Second and/or third degree burns >20% body surface area (BSA).
2. Second and/or third degree burns >10% body surface area (BSA) in patients under 10 years old or
over 50 years old.
3. Burns that involve the face, hands, feet, genitalia, perineum or major joints.
4. Electrical burns, including lightning injury.
5. Chemical burns.
6. Circumferential burns.
7. Inhalational injury.
Parkland Formula for Fluid Replacement:
4 ml x (body wt in kg) x (% BSA burned) = total fluids for 24 hrs
Give ½ in the first 8 hrs; give remainder over next 16 hrs.
Pearls (Electrical)
·
·
·
·
Do not contact the patient until you are certain the source of the electric shock has
been disconnected.
Attempt to locate contact points, (entry wound where the AC source contacted the
patient; an exit at the ground point); both sites will generally be full thickness.
Cardiac monitor; anticipate ventricular or atrial irregularity to include V-Tach, V-Fib,
heart blocks, etc.
Attempt to identify the nature of the electrical source (AC vs DC), the amount of
voltage and the amperage the patient may have been exposed to during the electrical
shock.
Pearls (Chemical)
·
Certainly 0.9% NaCl Sol’n or Sterile Water is preferred;
however if it is not readily available, do not delay; use tap
water for flushing the affected area or other immediate
water sources. Flush the area as soon as possible with the
cleanest, readily available water or saline solution using
copious amounts of fluids.
Pediatric Burns Protocol
85
Cardiac Arrest Non-Traumatic Pediatric
Refer to Termination of Resuscitation
or DNR Protocol as Appropriate
Meets Criteria for Prehospital Death
Determination or DNR/POLST present?
YES
NO
IF HYPOXIA IS THE CAUSE OF THE ARREST,
EARLY VENTILATION IS RECOMMENDED
Begin Age Appropriate CPR
Push Hard (1.5 Inches Infant 2 Inches in
Children) Push Fast (≥ 100/min)
P
VF/VT
P
P
Defibrillate at 2 J/kg
P
E
Continue CPR for 2
Minutes
E
A
IV Access
A
P
IO Access
P
YES
E
Apply AED and Defib if Prompted
E
P
Apply Cardiac Monitor
P
Rhythm Shockable?
NO
P
Asystole/PEA
P
E
Continue CPR for 2
Minutes
E
A
IV Access
A
IO Access
P
Rhythm Shockable?
YES
E
Defibrillate if
Prompted(AED)
E
P
Not To Exceed Adult
Dose
P
E
Continue CPR for 2
Minutes
E
P
EPINEPHRINE 0.01
mg/kg 1:10,000 IV/
IO or 0.1 mg/kg
1:1,000 ETT Every 35 Minutes
P
A
Consider
Extraglottic Airway
A
P
Consider ETT
P
EPINEPHRINE 0.01
mg/kg 1:10,000 IV/
IO or 0.1 mg/kg
1:1,000 ETT Every 35 Minutes
P
A
Consider
Extraglottic Airway
A
P
Consider ETT
P
NO
Rhythm Shockable?
NO
Rhythm Shockable?
E
Continue CPR for 2
Minutes
E
P
P
YES
NO
NO
Rhythm Shockable?
YES
YES
E
Defibrillate if
Prompted(AED)
E
P
Not To Exceed Adult
Dose
P
E
Continue CPR for 2
Minutes
E
P
AMIODARONE
5 mg/kg IV/IO May
Repeat Once After
5th Shock
Use VF/VT Side as
Indicated
Use Asystole/PEA Side as Indicated
Check Pulse if Organized Rhythm
P
If Patient Remains Unresponsive to Resuscitation Efforts
Consider Termination of Resuscitation Protocol
Cardiac Arrest Pediatric
86
History
· Events leading to arrest
· Estimated down time
· Medications
· Existence of terminal illness
Signs and Symptoms
· Unresponsive
· Apneic
· Pulseless
Differential
· VF vs. Pulseless VT
· Asystole
· PEA
· Primary cardiac event vs. respiratory or
drug overdose
Pearls
· Respiratory failure resulting in cardiac arrest should be addressed as it is identified.
· Efforts should be directed at high quality and continuous compressions with limited
interuptions and early defibrillation when indicated.
· Consider early IO placement if IV is difficult.
· DO NOT HYPERVENTILATE.
· Reassess and document ETT placement using auscultation and ETCO2 capnography.
· Switch compressors every two minutes.
· Try to maintain patient modesty.
· Mechanical chest compression devices should be used if available and appropriate
for patient age/size in order to provide for consistent uninterrupted chest
compressions and crew safety.
· Adult paddles/pads may be used on children weighing greater than 15kg.
H’s & T’s (reversible causes)
· Hypovolemia – Volume infusion
· Hypoxia – Oxygenation & ventilation, CPR
· Hydrogen ion (acidosis) – Ventilation, CPR
· Hypo/Hyperkalemia – Calcium Chloride, Glucose, Sodium Bicarbonate, Albuterol
· Hypothermia - Warming
· Tension pneumothorax – Needle decompression
· Tamponade, cardiac – Volume infusion
· Toxins – Agent specific antidote
· Thrombosis, pulmonary – Volume infusion
· Thrombosis, coronary – Emergent PCI
Pediatric Cardiac Arrest (Non-Traumatic)
87
Pediatric Drowning
Airway protected &
ventilation adequate?
No
Yes
E
1.
2.
3.
4.
CAVEATS:
Adequate ventilation is KEY!!!
For patients breathing on own, start
oxygen 15L NRB; for patients not
adequately breathing à BVM
Do not suction foam in airway, just
For drowning victims in cardiac
compressions)
Pediatric Drowning Protocol
88
Oxygen 15L NRB
SpO2
P
Capnography
A
ALBUTEROL
P
Consider 12-Lead ECG
History
· Submersion in water regardless
of depth
· Possible history of trauma (dive)
· Duration of immersion
· Temperature of water or
possibility of hypothermia
· Degree of water contamination
Signs and Symptoms
· Unresponsive
· Decreased or absent vital signs
· Vomiting
· Coughing, wheezing, rales,
stridor, rhonchi
· Apnea
· Frothy/foamy sputum
Differential
· Trauma
· Pre-existing medical condition
· Barotrauma
· Decompression illness
· Post-immersion syndrome
Pearls
· Recommended Exam: Trauma Survey, Head, Neck, Chest, Abdomen, Back,
Extremities, Skin, Neuro.
· Ensure scene safety.
· Hypothermia is often associated with submersion incidents.
· All patients should be transported for evaluation because of potential for
worsening over the next several hours.
1.
2.
3.
4.
CAVEATS:
Adequate ventilation is KEY!!!
For patients breathing on own, start
oxygen 15L NRB; for patients not
adequately breathing à BVM
Do not suction foam in airway, just
For drowning victims in cardiac arrest,
emphasis should be on good
compressions)
QI Metrics
· Complete and submit the SNHD Submersion Incident Report Form.
Pediatric Drowning Protocol
89
Pediatric Environmental Illness / Hyperthermia
E General Pediatric Assessment
(if available)
Remove tight clothing
Passive cooling measures
E
Symptom Severity
E
Heat Stroke
High body temp >104 f
hot, dry skin
hypotension, altered mental
status/coma
Heat Exhaustion
Elevated body temp
cool, moist skin
weakness, anxious tachypnea
Heat Cramps
Normal to elevated body temp,
weakness, muscle cramping
E
PO fluids as tolerated
as indicated
Syncope as indicated
Vascular Access
A
P
NS bolus
20 ml/kg IV/IO;
repeat to effect
age appropriate
SBP ≥70 + 2 x Age;
max 60 mL/kg
E
Vascular Access
NS bolus
20 ml/kg IV/IO;
repeat to effect
age appropriate
SBP ≥70 + 2 x Age
max 60 mL/kg
A
Cardiac monitor
Poor
perfusion?
P
Cardiac monitor
Yes
No
Exit to appropriate
Shock or Trauma
Protocol as indicated
Poor perfusion?
Yes
No
Continue General
Patient Care and
Transport
Pediatric Environmental Illness / Hyperthermia Protocol
90
History
· Age, very old and young
· Exposures to increased
temperatures and/or humidity
· Time and duration of exposure
· Poor PO intake, extreme exertion
· Fatigue and/or muscle cramping
Signs and Symptoms
· AMS/coma
· Hot, dry, or sweaty skin
· Seizures
· Nausea
Differential
· Fever
· Dehydration
· Medications
· Hyperthyroidism
· DTs
· Heat cramps, heat exhaustion, heat stroke
· CNS lesions or tumors
Pearls
· Recommended exam: Mental Status, Skin, Heart, Lung, Abdomen, Extremities, Neuro.
· Extremes of age are more prone to heat emergencies.
· Cocaine, amphetamines, and salicylates may elevate body temperatures.
· Sweating generally disappears as body temperatures rise over 104° F (40° C).
· Intense shivering may occur as patient is cooled.
· Active cooling includes application of cold packs or ice (not directly on skin), fanning
either by air conditioning or fanning.
Heat Cramps
· Consist of benign muscle cramping caused by dehydration and is not associated with an
elevated temperature.
Heat Exhaustion
· Consists of dehydration, salt depletion, dizziness, fever, AMS, headache, cramping,
N/V. Vital signs usually consist of tachycardia, hypotension and elevated temperature.
Heat Stroke
· Consists of dehydration, tachycardia, hypotension, temperature >104° F (40° C)
and AMS.
Pediatric Environmental Illness / Hyperthermia Protocol
91
Pediatric Environmental Illness / Hypothermia
E General Pediatrc Assessment
(if available)
Remove wet clothing
Dry/warm patient
Passive warming measures
E
Hypothermia/Frost
Bite
Localized cold injury
E
Systemic hypothermia
Awake with/without
altered mental status
General wound care
DO NOT rub skin to warm
DO NOT allow refreezing
Respiratory
distress?
Unresponsive
Yes
Respiratory
Distress
No
E
A
P
A
Active warming measures
Yes
Pulse present?
Vascular Access
Cardiac monitor
NS bolus
20 ml/kg IV/IO;
repeat to age appropriate effect
SBP ≥70 + 2 x Age
max 60 ml/kg
General Pediatric
Trauma Assessment
Pediatric Shock
(Non-Trauma)
and Transport
Pediatric Environmental Illness / Hypothermia Protocol
92
No
Cardiac Arrest
History
· Age, very young and old
· Exposure to decreased
temperatures, but may occur in
normal temperatures
· Drug or alcohol use
· Infections/sepsis
· Time of exposure/wetness/wind
chill
Signs and Symptoms
· AMS/coma
· Cold, clammy
· Shivering
· Extremity pain
· Bradycardia
Differential
· Sepsis
· Hypoglycemia
· Stroke
· Head injury
· Spinal cord injury
Pearls
· Recommended exam: Mental Status, Heart, Lung, Abdomen, Extremities, Neuro.
· Extremes of age are more prone to cold emergencies.
· Obtain and document patient temperature.
· If temperature is unknown, treat the patient based on suspected temperature.
· Hot packs can be used on the armpit and groin; care should be taken not to place the
packs directly on the skin.
Hypothermia Categories
· Mild 90°- 95° F (33°- 35° C)
· Moderate 82°- 90° F (28°- 32° C)
· Severe <82° F (<28° C)
Hypothermia Mechanisms
· Radiation
· Convection
· Conduction
· Evaporation
Pediatric Environmental Illness / Hypothermia Protocol
93
Neonatal Resuscitation
E
Assist mother with delivery as
needed
Obstetrical Emergency
Term gestation?
Breathing or crying?
Good tone?
Yes
Provide warmth
Assure open airway
Dry baby
E
No
E
Caveats:
- Deep airway suctioning is
no longer recommended
- Traditional CPR 3:1 ratio
is standard for newborns
- Most newborns requiring
resuscitation will respond
to BVM, compressions
and Epi; for those that
don’t, consider
hypovolemia,
pneumothorax, and/or
hypoglycemia (BG <40)
Warm, open airway
Dry, stimulate baby
HR <100, gasping, or
apnea?
No
Labored breathing or
persistent cyanosis?
No
Yes
E
P
w/ BVM
SpO2 monitoring
Yes
Cardiac monitor
HR <100?
No
E
Oxygen, keep SpO2 >94%
Maintain warmth
Yes
No
HR <60?
Yes
CPR 3:1 ratio
A
Vascular Access
HR <60?
No
Yes
EPINEPHRINE 1:10,000;
P 0.01 mg/kg IV/IO q 3-5 min as
needed for HR <60
Neonatal Resuscitation Protocol
94
Transport per Pediatric
Destination Protocol; Radio
Contact to receiving facility
History
· Due date
· Time contractions started/
duration/frequency
· Rupture of membranes
(meconium)
· Time and amount of any vaginal
bleeding
· Sensation of fetal movement
· Prenatal care
· Past medical and delivery history
· Medications
· Gravida/Para Status
· High risk pregnancy
Signs and Symptoms
· Spasmodic pain
· Vaginal discharge or bleeding
· Crowning or urge to push
· Meconium
Differential
· Abnormal presentation (breech, limb)
· Prolapsed cord
· Placenta previa
· Abruptio placenta
Pearls
· Recommended Exam: Mental Status, Skin, HEENT, Neck, Chest, Heart, Lungs,
Abdomen, Neuro.
· Document all times (delivery, contraction, duration, frequency).
· Some bleeding is normal; copious amounts of blood or free bleeding is abnormal.
· Record APGAR at one and five minutes after birth.
· APGAR of 7-10 is normal, while 4-7 require resuscitative measures
· Transport mother and infant together whenever possible.
APGAR
· Activity/Muscle Tone
· Pulse
· Grimace/Reflex Irritability
· Appearance/Skin Color
· Respiration
Score=0
Absent
Absent
No response
Blue-Grey, pale all over
Absent
Score=1
Arms/legs flexed
Below 100
Grimace
Normal, except extremities
Slow, irregular
Score=2
Active Movement
Above 100
Sneeze, cough, pulls away
Normal over entire body
Good, crying
Caveats:
- Deep airway suctioning no longer recommended.
- Traditional CPR 3:1 ratio is standard for newborns.
- Most newborns requiring resuscitation will respond to BVM, compressions and Epinephrine; for those that don’t,
consider hypovolemia, pneumothorax, and/or hypoglycemia (BG <40).
Neonatal Resuscitation Protocol
95
Pediatric Overdose / Poisoning
E
If ingestion occurred within one hour of EMS arrival, administer
ACTIVATED CHARCOAL 1.0 gm/kg PO; min dose 10 gm; max dose
50 gm
P
Endotracheal Intubation if indicated
A
P
Consider cardiac monitor
Consider potential cause of
signs/symptoms
Opiate
OD
A
Dystonic
Reaction
Cyanide
NALOXONE
0.1 mg/kg
IN/IM/IV;
may repeat to
a max dose of
10 mg
A
BENADRYL
1.0 mg/kg
IM/IV; max
dose 50 mg
P
HYDROXOCOBALAMIN
70 mg/kg over 15
minutes
if available
TCA/ASA
OD
Calcium
Channel
Blocker OD
Beta Blocker
OD
Wide
QRS
Bradycardic
and
Hypotensive
Bradycardic
and
Hypotensive
1.0 mEq/kg of
8.4% solution
SODIUM
BICARBONATE
IV; use 4.2% for
neonate
P
20 mg/kg CALCIUM
CHLORIDE (10%) slow IV
P
GLUCAGON
0.5 mg IV/IM;
may repeat once in 3-5 min
Reassess and Transport as
Appropriate
Pediatric Overdose / Poisoning Protocol
96
Revised 4/1/2015
Organophosphate
Toxicity
P
ATROPINE
0.02 mg/kg IV
q 15 min as needed
to decrease
secretions and
ventilatory
resistance;
min dose 0.1 mg
History
· Ingestion or suspected ingestion
of a potentially toxic agent
· Substance ingested, route,
quantity
· Time of ingestion
· Reason (suicidal, accidental,
criminal)
· Available medications in home
· Past medical history, medications
Signs and Symptoms
· Hypotension/hypertension
· Decreased respiratory rate
· Tachycardia, dysrhythmias
· Seizures
· SLUDGE
· Malaise, weakness
· GI symptoms
· Dizziness
· Syncope
· Chestpain
Differential
· TCA overdose
· Acetaminophen OD
· Aspirin
· Depressants
· Stimulants
· Anticholinergic
· Cardiac medications
· Solvents, alcohols, cleaning agents,
insecticides
Pearls
· Pediatric patients should be evaluated by a physician if an overdose/poisoning is
suspected regardless of agent, amount or time.
· Recommended exam: Mental Status, Skin, HEENT, Heart, Lung, Abdomen, Extremities,
Neuro.
· Overdose or toxin patients with significant ingestion/exposure should be closely
monitored and aggressively treated. Do not hesitate to contact medical control if
needed.
· In the case of cyanide poisoning, altered mental status may be profound. Profound
altered mental status can be defined as a deficit that includes disorientation,
· Poison Control: 1-800-222-1222
· Do not use Activated Charcoal if altered mental status, caustic, hydrocarbon or heavy
metal ingestion.
Agents
· Acetaminophen: Initially normal or N/V. Tachypnea and AMS may occur later. Renal
dysfunction, liver failure and/or cerebral edema may manifest.
· Depressants: Decreased HR, BP, temp and RR.
· Anticholinergic: Increased HR, increased temp, dilated pupils and mental status
changes.
· Insecticides: May include S/S of organophosphate poisoning.
· Solvents: N/V, cough, AMS.
· Stimulants: Increased HR, BP, temp, dilated pupils, seizures and possible violence.
· TCA: Decreased mental status, dysrhythmias, seizures, hypotension, coma, death.
Pediatric Overdose / Poisoning Protocol
97
Revised 4/1/2015
Pediatric Pain Management
Appropriate treatment protocol
E
Comfort measures, i.e. patient positioning,
splinting, ice, etc.
A
Vascular Access
P
Cardiac monitor
For severe pain consider:
UP TO:
MORPHINE 0.1 mg/kg IM/IV;
max single dose 10 mg
OR
P
FENTANYL 1.0 mcg/kg IN/IM/IV;
max single dose 100 mcg
Additional FENTANYL doses require a
physician order
P
ONDANSETRON
Contact Medical Control for additional doses
Continue General
Pediatric Assessment
Pediatric Pain Management Protocol
98
**Round up to nearest ½
pill
History
· Age
· Location, duration
· Severity (1-10)
· Pregnancy status
· Drug allergies and medications
Signs and Symptoms
· Severity (pain scale)
· Quality
· Radiation
· Relation to movement,
respiration
· Increased with palpation of
area
Differential
· Musculoskeletal
· Visceral (abdominal)
· Cardiac
· Pleural, respiratory
· Neurogenic
· Renal (colic)
Pearls
· Recommended exam: Respiratory Status, Mental Status, Area of pain, Neuro.
· Pain severity (1-10) is a vital sign to be recorded before and after medication
administration and patient hand off.
· Monitor BP and respirations closely as sedative and pain control agents may cause
hypotension and or respiratory depression.
· Consider patient’s age, weight, clinical condition, use of drugs/alcohol, exposure to
opiates when determining initial opiate dosing. Weight based dosing may provide a
standard means of dosing calculation but it does not predict response.
· Exercise caution when administering opiates and benzodiazepines; this combination
results in deeper anesthesia with significant risk of respiratory compromise.
· Burn patients may require more aggressive dosing.
QI Metrics
· Vital signs with O2 sats documented.
· Pain scale documented before and after each intervention.
· Repeat vital signs after each intervention.
Pediatric Pain Management Protocol
99
Pediatric Respiratory Distress
No
E
adequate?
Yes
Yes
Wheezing or
Bronchospasm
E
A
P
Stridor
ALBUTEROL
assist patient w/own MDI
ALBUTEROL
PT >2 y/o with history of
wheezing IPRATROPIUM
2.5 ml 0.02% solution
SVN once; or
DuoNeb 3.0 ml SVN once
A
A
P
A
Nebulized NS
SVN
Provide comfort
measures
Consider Vascular
Access
For suspected
Croup, EPINEPHRINE
1:1000
3-5 mg SVN,
if SpO2 <94%
Consider
Vascular Access
Consider
Allergic Reaction
Pediatric Respiratory Distress Protocol
100
History
· Asthma
· Home treatment (oxygen,
nebulizers)
· Medication
· Toxic exposure
Signs and Symptoms
· Pursed lip breathing
· Decreased ability to speak
· Increased respiratory rate and
effort
· Wheezing, rhonchi
· Use of accessory muscles
· Fever, cough
· Tachycardia
Differential
· Asthma
· Anaphylaxis
· Aspiration
· Pleural effusion
· Pneumonia
· Pneumothorax
· Pericardial tamponade (trauma)
· Hyperventilation
· Inhaled toxin
Pearls
· Be prepared to assist ventilations as needed.
· Recommended exam: Mental Status, HEENT, Skin, Neck, Heart, Lungs, Abdomen,
Extremities, Neuro.
· Pulse oximetry and end tidal continuous waveform capnography must be monitored.
· Consider MI.
· Allow the patient to assume a position of comfort.
Pediatric Respiratory Distress Protocol
101
Pediatric Seizure
Patient febrile?
Yes
E
Cool the patient
No
Patient actively
seizing?
Yes
Patient have a
history of
seizures?
No
E
No
E
Yes
E
A
P
No
BG <60mg/dl?
Vascular Access
Cardiac monitor
Yes
MIDAZOLAM 0.1 mg/kg,
IN/IM/IV; max dose 5.0 mg
OR
DIAZEPAM 0.1 mg/kg
IM/IV/PR; max dose 5.0 mg
D10, 5ml/kg IV max single
dose 250ml
A
Yes
BG <60mg/dl?
GLUCAGON 0.5 mg IM for
no IV access
Persistent (status)
or recurrent
seizure?
Yes
E
A
Vascular Access
No
E
Cardiac monitor
P
MIDAZOLAM 0.1 mg/kg,
IN/ IM/IV; max dose 5.0 mg;
OR
DIAZEPAM 0.1 mg/kg
IM/IV/PR;
max dose 5.0 mg; OR
Pediatric Seizure Protocol
102
Revised 4/1/2015
Continue General
Pediatric Assessment
History
· Reported or witnessed seizure
activity
· Previous seizure history
· Seizure medications
· History of diabetes
· Time of seizure onset
· Number of seizures
· Alcohol use, abuse or abrupt
cessation
· Fever
Signs and Symptoms
· Decreased mental status
· Sleepiness
· Incontinence
· Observed seizure activity
· Evidence of trauma
· Unconsciousness
Differential
· CNS trauma
· Tumor
· Metabolic, hepatic or renal failure
· Hypoxia
· Electrolyte abnormality (Na, Ca, Mg)
· Drugs, medications non-compliance
· Infection, fever
· Alcohol withdrawal
· Hyperthermia
· Hypothermia
Pearls
· Recommended exam: Mental Status, HEENT, Heart, Lungs, Extremities, Neuro.
· Benzodiazepines are effective in terminating seizures; do not delay IM/IN
administration while initiating an IV.
· Status epilepticus is defined as two or more seizures successively without an
intervening lucid period, or a seizure lasting over five minutes.
· Grand mal seizures (generalized) are associated with loss of consciousness,
incontinence and oral trauma.
· Focal seizures affect only part of the body and are not usually associated with a loss
of consciousness.
· Be prepared to address airway issues and support ventilations as needed.
· Consider cardiac and ETCO2 monitoring.
Pediatric Seizure Protocol
103
Pediatric Shock
Estimated Minimum
Systolic
BP Calculation
(Age in Years x 2) + 70
BP calculation
applies up to age
10 years
E
Oxygen 15L NRB
A
Vascular Access
P Cardiac monitor/Capnography
Alternative appropriate treatment
Trauma related
General Trauma
For patients with
known adrenal
insufficiency, administer
patient’s own Solu-Cortef
(hydrocortisone) as
prescribed
Non-Trauma
related
BG <60mg/dl
BG <40mg/dl
in newborn
E
BG >250mg/dl
BG normal
ORAL GLUCOSE if patient
protecting airway
E
NS bolus
A 10 ml/kg for hypotension;
may repeat x 2
D10, 1ml/kg IV max single
dose 250ml
A
GLUCAGON
0.5 mg IM (<20 kg);
1.0 mg IM (>20kg) for no
IV access
NS bolus
20 ml/kg;
A
may repeat x 2 with
no rales on lung exam
P
Pediatric Shock Protocol
104 Revised 4/1/2015
Consider DOPAMINE
5-20 mcg/kg/min;
titrate to SBP
>70mmHg + 2 x Age
History
· Blood loss-vaginal bleeding,
ectopic, GI bleeding or AAA
· Fluid loss-vomiting, diarrhea,
fever
· Infection
· Cardiac tamponade
· Medications
· Allergic reaction
· Pregnancy
· History of poor oral intake
Signs and Symptoms
· Restlessness, confusion
· Weakness, dizziness
· Weak rapid pulse
· Pale, cool, clammy skin
· Delayed capillary refill
· Hypotension
· Coffee-ground emesis
· Tarry stools
Differential
· Hypovolemic shock
· Cardiogenic shock
· Septic shock
· Neurogenic shock
· Anaphylactic shock
· Ectopic pregnancy
· Dysrhythmias
· Pulmonary embolis
· Vasovagal
For patients with known adrenal insufficiency, administer patient’s own
Solu-Cortef (hydrocortisone) as prescribed.
Causes of Adrenal Insufficiency:
Addison’s Disease
Congenital Adrenal Hyperplasia
Long term administration of steroids
Others
Pearls
Neuro.
· Hypotension can be defined as a systolic BP of <90. This is not always reliable and
should be interpreted in context and patient’s typical BP, if known. Shock may
present with a normal BP initially.
· Shock often is present with normal vital signs and may develop insidiously.
Tachycardia may be the only manifestation.
· Consider all possible causes of shock and treat per appropriate protocol.
·
Hypovolemic shock
· Hemorrhage, trauma, GI bleeding, ruptured aortic aneurysm or pregnancy-related
bleeding
Cardiogenic shock
· Heart failure, MI, cardiomyopathy, myocardial contusion, toxins
Distributive shock
· Sepsis, anaphylaxis, neurogenic, toxins
Obstructive shock
· Pericardial tamponade, pulmonary embolus, tension pneumothorax
Pediatric Shock Protocol
105
Pediatric Smoke Inhalation
E
P
Cardiac monitor
Vascular Access
A
NS bolus, 20 ml/kg up to 60 ml/kg
for hypoperfusion
Other treatment protocols as indicated
(Burns)
Yes
P
Cardiac arrest or
hypotension or profound
altered mental status?
HYDROXOCOBALAMIN
70mg/kg IV over 15 min
No
Transport to UMC Trauma
Pediatric Smoke Inhalation Protocol
106
History
· Exposed to smoke in a structure
fire
· Exposed to smoke in a vehicle fire
· Exposed to smoke from other
sources, industrial, confined
space, wilderness fire etc.
Signs and Symptoms
· Facial burns
· Singed nasal hairs or facial hair
· Facial edema
· Stridor
· Grunting respirations
Differential
· COPD
· CHF
· Toxic inhalation injury
· Caustic inhalation injury
Pearls
· Protect yourself and your crew.
· Have a high index of suspicion when treating patients at the scene of a fire.
· If the medication is not available on scene do not delay transport waiting for it.
· Carefully monitor respiratory effort and correct life threats immediately.
· Decide early on if you want to intubate as burned airways swell making intubation
difficult.
· Profound altered mental status can be defined as a deficit that includes disorientation,
Preparation and Administration of Hydroxocobalamin
Complete Starting Dose: 5 g
1. Reconstitute: Place the vial in an upright position.
Add 200 mL of 0.9% Sodium Chloride Injection* to the vial using the
transfer spike. Fill to the line.
*0.9% Sodium Chloride Injection is the recommended diluent (diluent
not included in the kit). Lactated Ringer's Solution and 5% Dextrose
Injection have also been found to be compatible with
hydroxocobalamin.
2. Mix: The vial should be repeatedly inverted or rocked, not shaken,
for at least 60 seconds prior to infusion.
3. Infuse Vial: Use vented intravenous tubing, hang and infuse
70 mg/kg over 15 minutes.
Pediatric Smoke Inhalation Protocol
107
Pediatric Tachycardia / Stable
(Normal Mental Status, Palpable Radial Pulse)
Narrow Complex
≤0.11 Sec
P
Vagal Maneuvers
P
Cardiac monitor
A
Vascular Access
P
12-Lead ECG
Undifferentiated
Monomorphic VT
Suspected to be SVT with
Aberrancy
Wide Complex
≥0.12 Sec
Regular Monomorphic VT
Torsades de Pointes
Successful?
Yes
P
No
P
AMIODARONE
5 mg/kg in 50 cc NS
over 20 min
MAGNESIUM
P SULFATE 25 mg/kg IV in
50 cc NS over 10 min
ADENOSINE
0.1 mg/kg
rapid IV push
not to exceed 6 mg
Successful?
Successful?
Yes
No
No
ADENOSINE
0.2 mg/kg
P
rapid IV push
not to exceed 12 mg
P
Sychronized
Cardioversion
start at 0.5 to 1 J/kg;
may use 2 J/kg
if unsuccessful;
Consider sedation
ETOMIDATE
0.15 mg/kg IV
Pediatric Tachycardia / Stable Protocol
108
Yes
Continue
General
Patient Care
History
· Medications
· Diet (caffeine)
· Drugs (cocaine,
methamphetamines)
heart
Signs and Symptoms
· Heart rate ≥ 180 in children
· Heart rate ≥ 220 in infants
· Diaphoresis
Differential
· Hypoxia
· Hypovolemia
· Hyperthyroidism
Pearls
Neuro.
· Carefully monitor patients as you treat them; stable tachycardias may convert to
unstable rhythms/conditions quickly.
· Sedate patients prior to cardioversion, if time allows.
· The most common tachyarrythmia in children is sinus.
Pediatric Tachycardia / Stable Protocol
109
Pediatric Tachycardia / Unstable
(Mental Status Changes, No Palpable Radial Pulse)
Narrow Complex
≤0.11 Sec
P
A
Wide Complex
≥0.12 Sec
Cardiac monitor
Vascular Access
Torsades de
Pointes
P
If IV established,
administer
ADENOSINE
0.2 mg/kg
rapid IV push
not to exceed 12 mg
P
Monomorphic
VT
increasing to 4 J/kg;
Consider sedation
ETOMIDATE
0 .15 mg/kg IV
Sychronized
Cardioversion
Start at 0.5 to 1 J/kg; may
use 2 J/kg If unsuccessful;
or defibrillate at 2 J/kg
increasing to 4 J/kg;
Consider sedation
ETOMIDATE 0.15 mg/kg IV
P
Rhythm change?
Rhythm
change?
Yes
No
P
NO
Sychronized
Cardioversion
start at 0.5 to 1 J/kg;
may use 2 J/kg
if unsuccessful;
Consider sedation
ETOMIDATE
0.15 mg/kg IV
P
MAGNESIUM
SULFATE
25 mg/kg IV
in 50 cc NS
over 10 min
Rhythm
change?
Yes
No
P
Yes
Rhythm
change?
Rhythm change?
AMIODARONE
5.0 mg/kg in 50 cc
NS over 20 mIn
Rhythm
change?
Yes
No
Yes
P
No
No
Yes
Transport
Continue
General
Patient Care
Transport
Continue
General
Patient Care
Pediatric Tachycardia / Unstable Protocol
110
Repeat Sychronized
Cardioversion or
defibrillate if VT not
resolved; assess
need for repeat
sedation; repeat
AMIODARONE
Rhythm
change?
No
Transport
History
· Medications
· Diet (caffeine)
· Drugs (cocaine,
methamphetamines)
heart
Signs and Symptoms
· Cardiac Arrest
· Heart rate ≥ 180 in children
· Heart rate ≥ 220 in infants
· Diaphoresis
Differential
· Hypoxia
· Hypovolemia
· Hyperthyroidism
Pearls
Neuro.
· If patient is in arrest, efforts should focus on quality chest compressions and rhythm
correction.
· Administer Adenosine at a proximal IV site, rapidly followed by a saline flush.
· The most common tachyarrythmia in children is sinus.
Pediatric Tachycardia / Unstable Protocol
111
Pediatric Ventilation Management
Use supplemental
oxygen to
maintain an
oxygen saturation
of >94%;
>90% for patients
on home oxygen
for chronic
conditions
E
Basic Airway Maneuvers
- Open airway, Chin lift/Jaw thrust
- NPA or OPA as needed
- Suction as needed
Respiratory Distress and/or
Protocol if needed
Consider Altered Mental Status/Syncope
Administer oxygen
E
BVM as needed
Intervention
effective?
No
Yes
Extraglottic Airway
A
ECG Monitor
Consider Sedation Administer MIDAZOLAM 0.1 mg/kg IV/IN Titrated to Effect. Maximum Single
Dose : 5 mg. Must be Given Slowly Over 3-5 Minutes. Additional Doses by Physician Order Only.
Or; KETAMINE 2 mg/kg IV Or 4 mg/kg IM
P
Maintain Sedation Administer DIAZEPAM 0.2mg/kg IV. Maximum dose 5 mg. May Repeat After 5
Minutes with Physician Order. Or;
DIAZEPAM 0.5 mg/kg PR via #5 or #8 French feeding tube, Maximum Dose 20 mg
Yes
Extraglottic/ETT
placement successful?
No
Able to ventilate
without extraglottic/
ETT in place?
Yes
No
P
Continue Care
and Transport as
Appropriate
Cricothyroidotomy
Pediatric Ventilation Management Protocol
112
Pearls
· Capnometry (Color) or capnography is mandatory with all methods of intubation. Document results.
· Continuous capnography (ETCO2) is mandatory for the monitoring of all patients with an ET tube.
· If an effective airway is being maintained by BVM and/or basic airway adjuncts (e.g. nasopharyngeal airway)
with continuous pulse oximetry values of ≥90%, or values expected based on pathophysiologic condition
with otherwise reassuring vital signs (e.g. pulse oximetry of 85% with otherwise normal vitals in a postdrowning
patient), it is acceptable to continue with basic airway measures instead of using an extraglottic airway device
or intubation.
· For the purposes of this protocol, a secure airway is achieved when the patient is receiving appropriate
oxygenation and ventilation.
· An Intubation Attempt is defined as passing the laryngoscope blade or endotracheal tube past the teeth or
inserted into the nasal passage.
· An appropriate ventilatory rate is one that maintains an ETCO2 of 35 - 45. Avoid hyperventilation.
· Paramedics should use an extraglottic airway device if oral-tracheal intubation is unsuccessful.
· Maintain C-spine stabilization for patients with suspected spinal injury.
· Cricoid pressure and BURP maneuver may assist with difficult intubations. They may worsen view in some cases.
· Gastric tube placement should be considered in all intubated patients if time allows.
· It is important to secure the endotracheal tube well.
Pediatric Ventilation Management
113
OPERATIONS
PROTOCOLS
114
COMMUNICATIONS
Telemetry contact should be established by radio.
Telephone contact may only be used if the call is recorded via a
phone patch through the FAO at 702-382-9007.
1. Telemetry contact shall be established:
A. For all Code 3 transports.
B. For any medical emergency in which the EMS provider’s judgment suggests consultation with a telemetry
physician is necessary.
C. For all trauma patients going to a trauma center.
D. When telemetry contact is required per protocol.
2. For patients who meet Trauma Field Triage Criteria, telemetry reports shall include:
A. Patient age
B. Gender
C. Mechanism of injury
D. Ambulatory at scene
E. Suspected injuries
F. Vital signs
G. Airway status
H. Neurologic status
I. ETA
J. An incident identifier if multiple patients are involved (e.g. fire department command code “Main Street
Command”)
.................
.................
3. For all other patients, telemetry reports shall include, at a minimum:
A. Attendant/vehicle identification
B. Nature of call: INFORMATION ONLY or REQUEST FOR PHYSICIAN ORDERS
C. Patient information (i.e. number, age, sex)
D. Patient condition (i.e. stable, full arrest)
E. History
1) Basic problem or chief complaint
2) Pertinent associated symptoms
3) Time since onset
4) Past history, if pertinent
F. Objective findings
1) General status of patient
2) Level of responsiveness
3) Vital signs
4) Pertinent localized findings
5) Working impression of patient’s problem
G. Treatment
1) In progress
2) Requests for drugs or procedures
H. Estimated time of arrival, including any special circumstances that may cause a delay in transport.
I. For patients meeting “Code White” or “Code STEMI” criteria, a preliminary telemetry report should be made to
notify the receiving facility of the type of activation, and an estimated arrival time. An “Information Only”
telemetry should follow once transport has been initiated.
COMMUNICATIONS
115
COMMUNICATIONS (Cont.)
Telemetry contact should be established by radio.
Telephone contact may only be used if the call is recorded via a
phone patch through the FAO at 702-382-9007.
4. Notification of transport shall be provided to the receiving hospital for ALL other calls.
A. Notification can be completed via:
1) Radio
2) Telephone
3) EMSystem
B. Notification reports shall include:
1) Patient age
2) Chief complaint
3) Type of bed required (monitored/unmonitored)
4) Unit number
5) ETA
5. Providers will relay assessment findings and treatment provided to the individual(s) assuming responsibility
for the patient(s).
6. Patient confidentiality must be maintained at all times.
7. All patients should be treated with dignity and respect in a calm and reassuring manner.
COMMUNICATIONS (Cont.)
116
DO NOT RESUSCITATE (DNR/POLST)
1. All patients with absent vital signs who do not have conclusive signs of death (refer to Prehospital Death
Determination protocol) shall be treated with life-resuscitating measures unless EMS personnel are presented
with a valid Do-Not-Resuscitate (DNR)/Physician Order for Life-Sustaining Treatment (POLST) Identification/Order.
A. A valid DNR Identification is a form, wallet card, or medallion issued by the Southern Nevada Health District,
Nevada Division of Public and Behavioral Health, or an identification issued by another state indicating a
person’s desire and qualification to have life-resuscitating treatment withheld.
B. A valid DNR Order is a written directive issued by a physician licensed in this state that life-resuscitating
treatment is not to be administered to a qualified patient. The term also includes a valid Do-Not-Resuscitate
order issued under the laws of another state.
C. A valid POLST form signed by a physician that records the wishes of the patient and directs a healthcare
provider regarding the provision of life-resuscitating treatment and life-sustaining treatment.
Note: Verbal instructions from friends or family members DO NOT constitute a valid DNR/POLST.
2. In preparation for, or during a inter-facility transfer, a valid DNR Order/POLST in the qualified patient’s medical
record shall be honored in accordance with this protocol.
3. If the EMS provider is presented with a DNR/POLST Order or Identification, he shall attempt to verify the validity
of the Order or Identification by confirming the patient’s name, age, and condition of identification.
4. The DNR/POLST Order or Identification shall be determined INVALID if at any time the patient indicates that he/she
wishes to receive life-resuscitating treatment. The EMS provider shall document the presence of the DNR/POLST
Order or Identification, and how the patient indicated that he/she wanted the Order or Identification to be revoked.
EMS personnel shall relay this information to any subsequent medical providers, including but not limited to,
flight crews and staff at the receiving medical facility.
5. Once the DNR/POLST Order or Identification is determined to be valid and has not been revoked by the patient, the
emergency care provider shall provide ONLY supportive care and withhold life-resuscitating treatment.
6. Faxed, copied or electronic versions of the DNR Identification/POLST are legal and valid.
Supportive Care:
Suction the airway
Administer oxygen
Position for comfort
Splint
Control bleeding
Provide pain medication (ALS only)
Provide emotional support
Contact hospice, home health agency, attending physician or hospital as appropriate
Be attentive of any actions the patient may take to revoke his authorization to withhold life-resuscitating
treatment
DO NOT RESUSCITATE (DNR/POLST)
117
DO NOT RESUSCITATE (Cont.)
Withhold Life-Resuscitating Treatment:
CPR and its components including:
Chest compressions
Defibrillation
Cardioversion
Assisted ventilation
Airway intubation
Administration of cardiotonic drugs
6. EMS personnel will document on the PCR the presence of the DNR/POLST Order or Identification. Documentation
should include the patient’s name, and the physician’s name and identification number, which are found on the
DNR/POLST Order or Identification.
7. An EMS provider who is unwilling or unable to comply with the DNR protocol shall take all reasonable measures
to transfer a patient with a DNR/POLST Order or Identification to another provider or facility in which the
DNR/POLST protocol may be followed.
DO NOT RESUSCITATE (Cont.)
118
DOCUMENTATION
1. A Patient Care Record (PCR) will be completed for each incident/patient encounter, in accordance with current
EMS Regulations. A patient is any individual that, upon contact with an EMS system, has any of the following:
A. A complaint or mechanism suggestive of potential illness or injury.
B. Obvious evidence of illness or injury.
C. An individual or informed 2nd/3rd party caller requests evaluation for potential illness or injury.
2. PCRs shall include no less than the following information:
A. Patient’s name, address, age, and sex;
B. Date and location of call;
C. Time of dispatch, arrival at scene, departure from scene, and arrival at hospital;
D. Mechanism of injury—chief complaint;
E. Medication(s) used by patient and allergies;
F. Pertinent patient history, including current medication(s) and allergies;
G. Signs and symptoms identified during patient assessment, and changes;
H. Care and treatment given at scene and during transport;
I. Patient destination;
J. Name of attendant(s);
K. If care is provided as authorized by protocol;
L. In cases involving cardiac monitoring, a copy of the ECG strip identifying all rhythm changes shall be included
as part of the PCR;
M. In cases of trauma, the patient’s trauma score, TFTC status, and any injury mitigation devices shall be
documented, i.e. car seats, seat belts, air bags, helmets, etc.;
N. At least one full set of vital signs;
1) Blood pressure
2) Heart rate
3) Respiratory rate
4) Temperature as indicated
5) Oxygen saturation as indicated
6) Reassessment after interventions, i.e. pain score after medications;
7) Any complications or other relevant information.
3. Any agency that provides patient care activities prior to the arrival of the transporting agency shall provide the
transporting agency with, at a minimum, a verbal report reflecting those activities. This verbal report must be
documented in the transporting agency’s PCR.
DOCUMENTATION
119
Active hostile incident
Assailants detained and
scene immediately safe?
No
·
Yes
Evacuate patients to the
triage/treatment area
·
While in the triage/treatment
area care will be provided as
directed in the Clark County
EMS System Emergency
Medical Care Protocols
Depending on patient load
and acuity request additional
resources as needed for
transport, including the use of
alternate transportation
methods.
Disposition of patients will be
directed through ICS taking
into consideration protocol
and available acute care
resources
·
If trained and properly
equipped as per the
Southern Nevada Fire
Operations Policy 11,
respond with law
enforcement as a Force
Protection Team to sort
patients for removal to the
cold zone.
Provide treatment for
immediate life threats.
Tag patients as indicated in
agency policy.
·
For the purpose of this manual, an active hostile incident can be
defined as any location where persons are under assault by whatever
method and teams comprised of police and fire department personnel
are needed to immediately enter the warm zone to provide initial
treatment for life threatening injuries and to complete patient “sift
and sort” procedures.
·
Active hostile incident scenes represent challenges in regard to the
provision of emergency care. Specific adherence to the Clark County
EMS System Emergency Medical Care Protocols may not be feasible in
these austere environments. Therefore, the Southern Nevada Health
District authorizes brief and limited departures from protocol.
·
When acting in a force protection team licensed providers may
perform needle decompression, basic airway maneuvers or apply a
tourniquet to complete or partial amputations regardless of observed
exsanguination.
·
Patients who are moved to the triage/treatment area will be treated
in accordance with the Clark County EMS System Emergency Medical
Care Protocols.
120
INTER-FACILITY TRANSFER OF
PATIENTS BY AMBULANCE
1. Ambulance attendants should only transfer a patient whose therapy required during the transfer lies within
the ambulance attendant’s capabilities, unless capable personnel accompany the patient.
A. Ambulance attendants are authorized to administer or monitor all medications listed on the official drug
inventory as appropriate for their level of licensure and as per protocol.
B. AEMT/EMT-I and Paramedic/EMT-P ambulance attendants are authorized to administer or monitor any
crystalloid IV solution during transport.
C. Arterial lines should be discontinued unless appropriate personnel from the initiating facility accompany
the patient.
D. Heparin locks/implantable catheters with/without reservoirs may be closed off and left in place. If they are
to be used during transport, then an IV drip should be established if tolerated by the patient.
E. IV pump systems should be discontinued unless capable personnel accompany the patient.
F. Orogastric or nasogastric tubes may be left in place and should either be closed off or left to suction per
order of the transferring physician.
G. Orthopedic devices may be left in place at the ambulance attendant’s discretion as to ability to properly
transport the patient with existing device(s) in place.
H. Trained personnel authorized to operate the apparatus should accompany any patient requiring mechanical
ventilation during transport. If the patient will require manual ventilatory assistance, then at least two
persons shall be available to attend to the patient.
2. Prior to the transfer, the transferring physician is responsible for notifying the receiving physician of the
following:
1) Reason for transfer
2) Patient condition
3) Estimated time of arrival
3. The transferring physician must provide the ambulance attendants with the name of the receiving facility and
receiving physician, copies of any available diagnostic tests, X-rays, medical records, copy of code status, DNR,
POLST, or advanced directive paperwork as applicable, any isolation precaution information, and the EMTALA
form prior to releasing the patient.
4. Any agency that provides patient care activities prior to the arrival of the transporting agency shall provide the
transporting agency with, at a minimum, a verbal report reflecting those activities. This verbal report must be
documented in the transporting agency’s PCR.
INTER-FACILITY TRANSFER OF PATIENTS BY AMBULANCE
121
PEDIATRIC PATIENT DESTINATION
Pediatric patients (<18 years of age) shall be transported in accordance with the following criteria:
1. Pediatric patients (including psychiatric patients) shall be transported, based on the preference of the parent
or legal guardian, to one of the following facilities:
A. St. Rose Dominican – Siena Campus
B. Summerlin Hospital Medical Center
C. Sunrise Hospital & Medical Center
D. University Medical Center
2. If the parent or legal guardian does not have a preference, the patient shall be transported to the closest of the
above facilities.
3. If, in the judgment of prehospital personnel, the transport time to one of the above facilities would be detrimental
to a critically ill/unstable pediatric patient, the patient should be transported to the closest Emergency
Department.
4. The patient may be transported to a non-designated facility:
A. At the request of the parent or legal guardian, and if the child is deemed stable by the EMS provider; or
B. The incident is greater than 50 miles from the closest pediatric facility; and
C. The receiving facility and physician are contacted and agree to accept the patient.
5. Pediatric sexual assault victims shall be transported as follows:
A. Victims <13 years of age shall be transported to Sunrise Hospital and Medical Center.
B. Victims 13 years of age and up to 18 years of age shall be transported to either Sunrise Hospital & Medical
Center or University Medical Center.
C. For sexual assault victims outside a 50-mile radius from the above facilities, the licensee providing emergency
medical care shall transport the patient to the nearest appropriate facility.
PEDIATRIC PATIENT DESTINATION
122
PREHOSPITAL DEATH DETERMINATION
For all emergency scenes where patient needs exceed available EMS resources, initial assessment
and treatment shall be in accordance with the START/SMART triage methodology.
1. Patients who appear to have expired will not be resuscitated or transported by Clark County EMS personnel if
any of the following obvious signs of death are present:
A.
B.
C.
D.
Body decomposition
Decapitation
Transection of thorax (hemicorpectomy)
Incineration
OR if ALL four (4) presumptive signs of death AND AT LEAST one (1) conclusive sign of death are identified.
The four (4) presumptive signs of death
that MUST be present are:
1) Unresponsiveness
2) Apnea
3) Pulselessness
4) Fixed, dilated pupils
Conclusive signs of death include:
1) Dependent lividity of any degree
2) Rigor mortis
3) Massive trauma to the head, neck
or chest with visible organ
destruction
2. If there is any question regarding patient viability, to include potential hypothermia, resuscitation will be
initiated.
3. Once it has been determined that the patient has expired and resuscitation will not be attempted:
A) Immediately notify the appropriate authority;
B) DO NOT leave a body unattended. You may be excused once a responsible person (i.e. Coroner’s investigator,
police, security, or family member) is present;
C) DO NOT remove any property from the body or the scene for any purpose;
D) NEVER transport/move a body without permission from the Coroner’s office except for assessment or
its protection.
If the body is in the public view and cannot be isolated, screened, or blocked from view, and is
creating an unsafe situation with citizens/family, the body can be covered with a clean,
STERILE BURN SHEET obtained from the EMS vehicle.
PREHOSPITAL DEATH DETERMINATION
123
PUBLIC INTOXICATION
1. A person who is suspected to be intoxicated and has no other emergent need should be
transported to an approved alcohol and drug abuse facility rather than a hospital’s emergency
department IF the patient meets ALL of the following criteria:
A. Patient is able to stand with minimal assistance of one or two people.
B. Vitals as follows:
1. Blood Pressure: Systolic: 90 – 180
Diastolic: 60 – 100
2. Pulse Rate: 60 – 120
3. Respiratory Rate: 12 – 22
4. Blood Glucose between 60 – 250
5. Glasgow Coma Score > 14
6. SPO2 >94% or 90% if smoker
7. No acute medical complications
8. No signs of trauma
9. No suspected head injury
10. Approval of the physician or medical staff upon assessment prior to transport to an
alternative facility
All of the above parameters must be met and the patient must be clinically stable.
2. If there is ANY doubt about whether the person is in need of emergency medical care, the
person should be transported to a receiving emergency facility.
Public Intoxication
124
QUALITY IMPROVEMENT REVIEW
When EMS or hospital personnel wish to have an incident involving patient care reviewed within the Clark County
EMS system, the following steps shall be taken:
1. The person requesting a review of an incident should contact the designated representative of the agency/
hospital involved to initiate the process. If after gathering appropriate information and discussing the incident
both parties are satisfied a problem does not exist, nothing further needs to be done.
2. If either party would like to pursue an investigation of the incident, the “Southern Nevada Health District EMS
Incident Report” should be completed and a copy should be forwarded to the OEMSTS.
3. Upon receipt of the “Southern Nevada Health District EMS Incident Report” OEMSTS staff will review the
case, gather information from the agencies/hospitals involved, and evaluate the need for further investigation.
The agency/hospital may be asked to conduct an internal investigation, involving their medical director when
appropriate, and provide a summary of their findings to the OEMSTS.
4. The personnel involved in the incident may be interviewed by the EMS medical director or his designee and
their agency/hospital medical director to gather additional information.
5. Upon completion of the investigation, a report will be prepared and given to the agency/hospital representatives
involved. Direct communication between the agency/hospital and complainant is recommended with a brief
written summary of actions taken provided to the OEMSTS.
6. A quarterly aggregate summary of the incidents reviewed by the OEMSTS will be prepared and reported at the
Quality Improvement Directors and Medical Advisory Board meetings.
7. All documentation and correspondence regarding this quality improvement activity; to monitor, review,
evaluate, and report on the necessity, quality, and level of care provided a patient is confidential pursuant to
NRS 49.117 – NRS 49.123, NRS 49.265, NRS 450B.810 and NRS 629.061.
QUALITY IMPROVEMENT REVIEW
125
TERMINATION OF RESUSCITATION
1. Resuscitation that is started in the field by licensed EMS personnel CANNOT be discontinued without a physician
order. Licensed EMS personnel are not obligated to continue resuscitation efforts that have been started by
other persons at the scene if the patient meets the criteria listed in the Prehospital Death Determination protocol.
This includes telephone CPR initiated by Emergency Medical Dispatchers.
2. Resuscitation started in the field may be discontinued only by physician order when the following
conditions have been met:
A. For medical arrest:
The patient remains in persistent asystole or agonal rhythm and has capnography <10
after twenty (20) minutes of appropriate Paramedic/EMT-P resuscitation, to include:
1) CPR
2) Effective ventilation with 100% oxygenation
3) Administration of appropriate ACLS medications
B. For traumatic arrest:
1) Open airway with basic life support measures
2) Provide effective ventilation with 100% oxygenation for two (2) minutes
3) Perform bilateral needle thoracentesis if tension pneumothorax suspected
C. The patient develops, or is found to have one of the following conclusive signs of death at
any point during the resuscitative effort:
1) Lividity of any degree
2) Rigor mortis of any degree
3. When resuscitation has been terminated in the field, all medical interventions shall be left in place.
4. If possible, do not leave a body unattended. Once a responsible person (i.e. Coroner’s investigator, police,
security, or family member) is present at the scene, you may be excused.
5. NEVER transport/move a body without permission from the Coroner’s office, except for assessment or its
protection.
If the body is in the public view and cannot be isolated, screened, or blocked from view, and is
creating an unsafe situation with citizens/family, the body can be covered with a clean,
STERILE BURN SHEET obtained from the EMS vehicle.
TERMINATION OF RESUSCITATION
126
TRANSPORT DESTINATIONS
1. Patients sustaining traumatic injuries shall be transported in accordance with the Trauma Field Triage
Criteria Protocol.
2. Patients sustaining burn injuries shall be transported in accordance with the Burns Protocol.
3. Pediatric patients (<18 years of age for transport purposes ONLY) shall be transported in accordance with the
Pediatric Destination Protocol.
4. Patients with evidence of an acute cerebrovascular accident shall be transported in accordance with the
Stroke Protocol.
5. Sexual assault victims shall be transported as follows:
A. Victims <13 years of age shall be transported to Sunrise Hospital & Medical Center.
B. Victims 13 years of age and up to 18 years of age shall be transported to either Sunrise Hospital & Medical
Center or University Medical Center.
C. Victims 18 years of age and older shall be transported to University Medical Center.
D. For sexual assault victims outside a 50-mile radius from the above facilities, the licensee providing
6. All patients in cardiac arrest or in whom the ability to adequately ventilate cannot be established should be
transported to the closest facility.
7. Stable patients should be transported to the hospital of their choice. If the patient does not have a preference, the
patient should be transported to the closest facility.
8. If a hospital declares an Internal Disaster, that facility is to be bypassed for ALL patients except patients in
cardiac arrest, or in whom the ability to adequately ventilate has not been established.
9. For patients outside a 50 mile radius from protocol designated transport destinations, the licensee providing
TRANSPORT DESTINATIONS
127
TRAUMA FIELD TRIAGE CRITERIA
A licensee providing emergency medical care to a patient at the scene of an injury shall use the following procedures
to identify and care for patients with traumas:
1. Step 1 – Measure vital signs and level of consciousness. If the patient’s:
A. Glasgow Coma Scale is 13 or less;
B. Systolic blood pressure is less than 90 mmHg; or
C. Respiratory rate is less than 10 or greater than 29 breaths per minute (less than 20 in infant aged less than
1 year), or is in need of ventilatory support
the adult patient MUST be transported to a Level 1 or 2 center for the treatment of trauma in accordance with
the catchment area designated. The pediatric patient MUST be transported to a pediatric center for the
treatment of trauma.
2. Step 2 – Assess anatomy of injury. If the patient has:
A. Penetrating injuries to head, neck, torso, or extremities proximal to elbow or knee;
B. Chest wall instability or deformity (e.g. flail chest);
C. Two or more proximal long-bone fractures;
D. Crushed, degloved, mangled, or pulseless extremity;
E. Amputation proximal to wrist or ankle;
F. Pelvis fractures;
G. Open or depressed skull fractures; or
H. Paralysis
the adult patient MUST be transported to a Level 1 or 2 center for the treatment of trauma in accordance with
the catchment area designated. The pediatric patient MUST be transported to a pediatric center for the
treatment of trauma.
3. Step 3 – Assess mechanism of injury and evidence of high-energy impact, which may include:
A. Falls
1) Adults: greater than 20 feet (one story is equal to 10 feet)
2) Children: greater than 10 feet or two times the height of the child
B. High-risk auto crash
1) Motor vehicle was traveling at a speed of at least 40 miles per hour immediately before the collision
occurred;
2) Intrusion, including roof: greater than 12 inches occupant site; greater than 18 inches any site;
3) Ejection (partial or complete) from automobile;
4) Motor vehicle rolled over with unrestrained occupant(s);
5) Death in same passenger compartment
C. Motorcycle crash greater than 20 mph
D. Auto vs pedestrian/bicyclist thrown, run over, or with significant (greater than 20 mph) impact
the patient MUST be transported to a Level 1, 2, or 3 center for the treatment of trauma in accordance with
the catchment area designated. For patients who are injured outside a 50-mile radius from a trauma center,
the licensee providing emergency medical care shall call and consider transport to the nearest receiving facility.
TRAUMA FIELD TRIAGE CRITERIA
128
TRAUMA FIELD TRIAGE CRITERIA (Cont.)
4. Step 4 – Assess special patient or system considerations, such as:
A. Older adults
1) Risk of injury/death increases after age 55 years
2) SBP less than 110 mmHg might represent shock after age 65 years
3) Low impact mechanisms (e.g. ground level falls) might result in severe injury
B. Children should be triaged preferentially to a trauma center.
C. Anticoagulants and bleeding disorders: Patients with head injury are at high risk for rapid deterioration.
D. Burns
1) Without other trauma mechanisms: transport in accordance with the Burns protocol
2) With trauma mechanism: transport to UMC Trauma/Burn Center
E. Pregnancy greater than 20 weeks
F. EMS provider judgment
The person licensed to provide emergency medical care at the scene of an injury shall transport a patient to a
designated center for the treatment of trauma based on the following guidelines:
St. Rose Dominican Hospital - Siena Campus (Level 3 Trauma Center) Catchment Area
All trauma calls that meet Step 3 or in the provider’s judgment meet Step 4 of the Trauma Field Triage Criteria
Protocol and occur within the City of Henderson or the geographical area bordered by Interstate 15 to the west
and Sunset road to the north, and the county line to the east, are to be transported to St. Rose Dominican
Hospital – Siena Campus and the medical directions for the treatment of the patient must originate at that center;
Sunrise Hospital & Medical Center (Level 2 Trauma Center) Catchment Area
All adult trauma calls and pediatric Step 3 trauma calls that meet the Trauma Field Triage Criteria Protocol and
occur within the geographical area bordered by Paradise Road to the west, Sahara Avenue to the north, Sunset
Road to the south, and the county line to the east, are to be transported to Sunrise Hospital & Medical Center
and the medical directions for the treatment of the patient must originate at that center;
In addition, adult trauma calls that meet Step 1 or 2 of the Trauma Field Triage Criteria Protocol and occur within
the St. Rose Dominican Hospital – Siena Campus Catchment Area, City of Henderson, or the geographical area
bordered by Paradise Road to the west continuing along that portion where it becomes Maryland Parkway, Sunset Road
to the north, and the county line to the east, are to be transported to Sunrise Hospital & Medical Center and the medical
directions for the treatment of the patient must originate at that center.
University Medical Center (Level 1 Trauma Center and Pediatric Level 2 Trauma Center) Catchment Area
All trauma calls that meet the Trauma Field Triage Criteria and occur within any other area of Clark County are
to be transported to University Medical Center/Trauma and the medical directions for the treatment of the
patient must originate at that center.
All pediatric Step 1 and Step 2 trauma calls that occur within Clark County are to be transported to University
Medical Center/Trauma and medical directions for the treatment of the patient must originate at that center.
In addition, adult trauma calls that meet Step 1 or 2 of the Trauma Field Triage Criteria Protocol and occur in the
geographical area bordered by Paradise road to the east, Sunset Road to the north, Interstate 15 to the west,
and the county line to the south, are to be transported to University Medical Center/Trauma and the medical
directions for the treatment of the patient must originate at that center.
129
All trauma calls that meet the Trauma Field Triage Criteria Protocol, regardless of location, that are transported
by air ambulance are to be transported to University Medical Center/Trauma and the medical directions for
the treatment of the patient must originate at that center.
EXCEPTIONS:
1. Nothing contained within these guidelines precludes transport to any trauma facility if, in the provider’s
judgment, time to transport to the designated center would be unduly prolonged due to traffic and/or weather
conditions and might jeopardize the patient’s condition.
2. Additionally, nothing contained within these guidelines precludes transport to the closest facility if, in the
provider’s judgment, an ability to adequately ventilate the patient might result in increased patient mortality.
130
WAITING ROOM CRITERIA
Upon arrival in the emergency department, if transfer of care has not occurred in accordance with NRS 450B.790,
any patient, excluding patients placed on a legal psychiatric hold, meeting ALL the following criteria may be
placed in the hospital waiting room or other appropriate location:
1. Normal vital signs
A. Heart rate 60 - 100
B. Respiratory rate 10 - 20
C. Systolic BP 100 - 180
D. Diastolic BP 60 - 100
E. Room air pulse oximetry >94%
F. Alert and oriented x 4
2. Did not receive any parenteral medications during EMS transport except a single dose of a narcotic and/or
an anti-emetic.
3. In the judgment of the Paramedic/EMT-P, does not require continuous cardiac monitoring. Note: Any ECG
monitoring initiated by a transferring facility may not be discontinued by EMS personnel.
4. Can maintain a sitting position without adverse impact on their medical condition.
5. Is left with a verbal report to hospital personnel.
WAITING ROOM CRITERIA
131
PROCEDURES
PROTOCOLS
132
CERVICAL STABILIZATION
LEVEL: EMT/AEMT/Paramedic
Cervical stabilization is indicated in any patient who meets the indications (A-E) below:
Indications:
This procedure may be performed on any patient with potential for spinal injury
based upon the following (NEXUS) criteria:
A. Midline cervical spinal tenderness
B. Focal neurologic deficit
C. Altered mental status
D. Evidence of drug and/or alcohol intoxication
E. Any painful, distracting injury
Contraindications:
Cervical stabilization is NOT performed in the following conditions:
A. Penetrating trauma to the head and/or neck and no evidence of spinal injury
B. Injuries where placement of the collar might compromise patient
assessment, airway management, ventilation and/or hemorrhage control
C. Patients in cardiac arrest
Key procedural considerations:
A. If (A-E) above are ALL NEGATIVE, cervical stabilization is not required.
B. If required, cervical stabilization is the placement of an approved, properlysized cervical collar before the patient is moved.
C. Backboards are only indicated for extrication and patient movement. Patients
are not to be transported on backboards (unless movement off the backboard
would delay immediate transport of patients with life-threatening injuries
or acute spinal injuries).
D. Tape, head straps, wedges, and head and/or neck support devices are not
recommended.
E. Patients found in motor vehicles should be asked if they are able to exit
the motor vehicle on their own. If so, they should be assisted to a soft
stretcher and secured for transport. Patients unable to exit the vehicle on
their own accord should be removed by the appropriate extrication method.
F. Once on the stretcher, the patient may be moved to a semi-Fowler’s or
high-Fowler’s position for comfort.
G. If a backboard is used for extrication or movement, the patient should be
immediately moved to a soft mattress, if possible.
H. In special situations, alternate stabilization devices (e.g. vacuum mattress,
KED, etc. may be used as indicated).
I. Pediatric patients may be stabilized in an approved car seat or with a
commercial pediatric stabilization device.
CERVICAL STABILIZATION
133
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
LEVEL: Paramedic
Indications:
This procedure may be performed on any patient 18 years old or older in CHF,
Respiratory Distress with Bronchospasm, and pneumonia, who has TWO of the
following:
A. Retractions or accessory muscle use
B. Respiratory rate >25 per minute
C. SpO2 ≤94%
Contraindications:
A. Apnea
B. Vomiting or active GI bleed
C. Major trauma/pneumothorax
D. Altered Mental Status
Use device per
manufacturer
instructions
A. Assess patient and document VS, SpO2 and ETCO2 prior to applying oxygen.
B. Select the appropriate size face mask for the patient.
C. Inform patient about procedure process.
D. Gradually increase the flow rate, slowly reaching the desired CPAP pressure.
E. Secure face mask onto patient face using the head harness.
F. Check the mask and tubing for leaks.
G. Reassess patient and document every five minutes.
H. If patient develops any of the contraindications or requires definitive
airway control, discontinue CPAP and provide necessary airway control.
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
134 Revised 1-15-15
ELECTRICAL THERAPY/DEFIBRILLATION
LEVEL: Paramedic
Indications:
This procedure may be performed on any patient experiencing:
A. Ventricular fibrillation
B. Pulseless ventricular tachycardia
C. Torsades de Pointes
Contraindications: None
Use device per
manufacturer
instructions
A. The initial and subsequent attempts shall be at the energy level(s) sugggested
by the device manufacturer and/or the agency’s medical director.
B. Defibrillation should be immediately provided in an arrest WITNESSED by EMS
personnel. In an arrest that is UNWITNESSED by EMS personnel, two minutes
of CPR should be provided prior to defibrillation.
C. Patients with automatic implantable cardioverter-defibrillators (AICD) will need
external defibrillation if the AICD is ineffective.
D. If defibrillation is needed on a patient with a permanent implanted pacemaker,
the defibrillator paddles or self adhesive electrodes should be placed at least
one inch from the pulse generator of the pacemaker.
Initial attempt at pediatric defibrillation shall be at 2 J/kg. If unsuccessful,
defibrillation should be attempted at 4 J/k and continue at 4 J/k until
conversion occurs. Adult paddles/pads may be used in children weighing
more than 15 kg.
ELECTRICAL THERAPY/DEFIBRILLATION
135
ELECTRICAL THERAPY/SYNCHRONIZED
CARDIOVERSION
LEVEL: Paramedic
The patient MUST be on a cardiac monitor
and SHOULD have Vascular Access
Indications:
A. Ventricular tachycardia with inadequate perfusion
B. Supraventricular tachycardia with inadequate perfusion
C. Ventricular tachycardia with adequate perfusion, but refractory to drug
therapy
Adjunctive therapy: Consider sedation prior to defibrillation in the awake patient,
administer Etomidate 0.15 mg/kg IV.
A. Biphasic device: The initial and subsequent attempts shall be at the
energy level(s) suggested by the device manufacturer and/or the
agency’s medical director.
B. Monophasic device:
1. Ventricular dysrhythmias: 100 J escalating to 200, 300, and 360
2. Supraventricular dysrhythmias: 50 J with subsequent attempts at 100 J
Initial attempt at pediatric cardioversion shall be at 0.5 J/kg.
If unsuccessful, cardioversion should be attempted at 2 J/kg.
Adult paddle/pads may be used in children weighing more than 15 kg.
ELECTRICAL THERAPY/SYNCHRONIZED CARDIOVERSION
136
ELECTRICAL THERAPY/TRANSCUTANEOUS PACING
LEVEL: Paramedic
Indications:
A. Hemodynamically unstable bradycardia
B. Unstable clinical condition that is likely because of bradycardia
C. For pacing readiness (i.e. standby mode) in the setting of MI with
bradycardia, second degree type II AV block, third degree AV block,
new left or right alternating BBB or bifascicular block
D. Overdrive pacing of tachycardias refractory to drug therapy or
electrical cardioversion
Adjunctive therapy:
In the conscious patient with a systolic blood pressure of >90mmHg consider:
Sedation: Midazolam 0.1 mg/kg IN/IM/IV. May repeat every five minutes
at 0.05 mg/kg IN/IM/IV or;
Diazepam 5 mg IV. May repeat after five minutes with
physician order.
Analgesia: Morphine Sulfate up to 0.1 mg/kg slow IV to a maximum single
dose of 10 mg. May repeat every 10 minutes until pain is relieved
or respiratory/mental status depression occurs or;
Fentanyl up to 1.0 mcg/kg IN/IM/IV to a maximum single dose
of 100 mcg. May repeat dose after 10 minutes with physician
order or;
Hydromorphone up to 1.0 mg IV. May repeat dose after
ten minutes with physician order.
A. Apply pacing pads, begin pacing at a rate of 60 beats per minute at the
lowest available current.
B. Increase current by 20 milliamp increments until electrical capture.
C. In the event of electrical capture and no pulses, continue pacing
and CPR.
Pediatric pacing is by telemetry physician order only
ELECTRICAL THERAPY/TRANSCUTANEOUS PACING
137
ENDOTRACHEAL INTUBATION
LEVEL: Paramedic
1. All intubations MUST have initial, en route, and at transfer of care End-Tidal CO2
detection/capnography performed and recorded on the PCR.
2. All intubation attempts MUST be documented on the PCR.
Indications:
This procedure may be performed on any patient in whom attempts at basic airway
and ventilatory support are unsuccessful AND who has at least one of the following:
A. Hypoxia
B. Respiratory arrest/failure
Contraindications:
Absolute Contraindications: None
Relative Contraindications:
A. Presence of gag reflex
B. Suspected narcotic overdose/hypoglycemia prior to administration or
Naloxone/Glucose 50%
Adjunctive Therapy:
If patient is 12 years of age or greater, administer Etomidate 0.3 mg/kg IV
for induction.
If patient is less than 12 years of age, administer Midazolam 0.1 mg/kg IV/IN
titrated to effect. Maximum single dose: 5 mg. Must be given slowly over a
period of 3-5 minutes. Additional pediatric doses by telemetry physician order only.
Maintain patient sedation. Administer Midazolam 0.1 mg/kg IV/IN. May repeat
every five minutes at .05 mg/kg IV/IN/IM.
Check and prepare the endotracheal airway device
prior to insertion
A. Position head properly.
B. Insert blade while displacing tongue and elevate mandible with laryngoscope.
C. Introduce ET tube and advance to proper depth.
D. Inflate cuff to proper pressure and disconnect syringe.
E. Ventilate patient and confirm proper placement.
F. Verify proper tube placement by secondary confirmation such as capnography
or colorimetric device.
G. Secure device or confirm that the device remains properly secured.
ENDOTRACHEAL INTUBATION
138
ENDOTRACHEAL INTUBATION (Cont.)
LEVEL: Paramedic
Nasotracheal Intubation:
Contraindications:
A. Apnea or near-apnea
B. Suspected basilar skull, nasal, or midface fractures
C. Coumadin anticoagulation therapy or hemostatic disorders
D. Upper neck hematomas
E. Should NOT be attempted in children
Adjunctive Therapy:
Prep the nostrils with Phenylephrine 2-3 drops or 1-2 sprays in each nostril, and
Lidocaine 2% lubricant.
Check and prepare the
endotracheal airway device prior
to insertion
A. Position patient semi-Fowler, sitting or supine.
B. Insert lubricated ET tube into dilated nostril and advance straight back
(posteriorly).
C. Listen to end ET tube for sounds of patient’s breathing.
D. During inhalation, smoothly advance tube through glottic opening.
E. Inflate cuff to proper pressure and disconnect syringe.
F. Verify proper tube placement by secondary confirmation such as capnography
G. Secure device or confirm that the device remains properly secured.
ENDOTRACHEAL INTUBATION (Cont.)
139
EXTRAGLOTTIC AIRWAY DEVICE
LEVEL: AEMT/Paramedic
Indications:
This procedure may be performed on any patient in which attempts at basic airway
and ventilatory support are unsuccessful AND who has at least one of the following:
A. Hypoxia
C. Obtundation
D. Failed endotracheal intubation
Contraindications:
A. Gag reflex
B. History of esophageal trauma, or known esophageal disease
C. Recent ingestion of a caustic substance
D. Tracheostomy or laryngectomy
E. Suspected foreign body obstruction
Check and prepare the
extraglottic airway
device prior to insertion
A. Pre-oxygenate the patient.
B. Position the patient’s head in a neutral or slightly flexed position if no suspected
spinal injury (if a spine injury is suspected, maintain a neutral, in-line head
position).
C. Perform a tongue-jaw lift.
D. Insert device to proper depth. NEVER force. If device does not advance,
readjust the insertion.
E. Secure device in the patient (inflate cuff(s) with proper volume(s) and
immediately remove syringe).
F. Ventilate patient and confirm proper ventilation (correct lumen and proper
insertion depth) by auscultation bilaterally over lungs and over epigastrium.
G. Adjust ventilation as necessary (ventilate through additional lumen or slightly
withdraw tube until ventilation is optimized).
H. Verify proper tube placement by secondary confirmation such as capnography
I. Secure device or confirm that the device remains properly secured.
EXTRAGLOTTIC AIRWAY DEVICE
140
FIRST RESPONSE EVALUATE/RELEASE
LEVEL: Paramedic/AEMT
Inclusion Criteria:
A.
Coded and dispatched using MPDS as an Alpha or Omega category
B.
Patient age ≥ 18 ≤ 65
C.
Full assessment performed by first response
D.
Patient deemed to have decision making capacity
E.
Normal vital signs including SPO2
F.
Patient has a phone, ability and willingness to call 9-1-1 if their condition
worsens
G.
In the opinion of the paramedic and the patient it is safe to release until an
ambulance arrives
Exclusion Criteria:
A.
Abnormal vital signs including SPO2
B.
Pregnancy
C.
Any high risk complaints/symptoms
a.
Chest pain
b.
Signs/symptoms of possible stroke
c.
Allergic reaction
d.
Shortness of breath
e.
Abdominal pain/flank pain above umbilicus age >35
f.
Syncope, near syncope, dizziness
g.
Seizure
h.
History or sign of head trauma
i.
Active bleeding
j.
Threat to self or others
k.
Overdose or ingestional error
l.
Patients meets Trauma Field Triage Criteria
D.
No SNHD EMS Protocol indication for obtaining EKG or placing the patient on a
cardiac monitor
EMS patient care record must be completed within four hours of clearing the call
The Field Response Low-Risk Alpha Evaluate and Release Form must be completed and a
copy left with the patient for inclusion in the secondary responder’s patient care report
FIRST RESPONSE EVALUATE/RELEASE
141
HEMORRHAGE CONTROL TOURNIQUET
Indications:
This procedure may be performed on any patient that has bleeding from an
extremity than can not be controlled by direct pressure.
A. Apply tourniquet proximal to the bleeding site.
B. Absolute contraindication: Bleeding has stopped
C. If bleeding is not controlled, consider additional tightening or applying a second
tourniquet proximal side by side to the first.
D. Record the time of tourniquet application, on the patient, that is clearly visible.
HEMORRHAGE CONTROL TOURNIQUET
142
MEDICATION ADMINISTRATION
LEVEL: EMT/AEMT/Paramedic (based on medication)
Indications:
This procedure may be performed on any patient that requires the administration
of a medication.
Key procedural considerations (GENERAL):
A. Inquire about allergies and previous medication reactions
B. Check and recheck medication
C. Solution clarity and expiration date
D. Right drug
Right patient
Right dose
Right time
Right route
Right documentation
E. Dispose of syringe and other material in proper container
Intravenous and Intraosseous Bolus Medications
A. Identify and cleanse injection site closest to the patient
B. Administer correct dose at proper push rate
C. Turn IV on and adjust drip rate to TKO/KVO
Intramuscular and Subcutaneous Drug Administration
A. Needle should be 20 gauge or smaller
B. Locate administration site
Deltoid muscle
Vastus lateralis (lateral thigh) muscle
Ventrogluteal or dorsogluteal muscles (buttocks)
IM
Pull skin tight
Insert needle at a 90° angle to the skin
Advance into muscle layer
SQ
Pinch to lift skin slightly
Insert needle at a 45° angle to the skin
Advance into subcutaneous layer
MEDICATION ADMINISTRATION
143
MEDICATION ADMINISTRATION (Cont.)
LEVEL: EMT/AEMT/Paramedic (based on medication)
Mucosal Atomizer Device (MAD) Administration
Medications: Fentanyl, Midazolam, Naloxone Hydrochloride
A. Using the free hand, hold the crown of the head stable.
B. Place the tip of the MAD snugly against the nostril, aiming slightly up and
outward (toward the top of the ear).
C. Briskly compress the syringe to deliver half the medication into the nostril.
D. Move the device over to the opposite nostril and administer the remaining
medication.
Intravenous and Intraosseous Bolus Medications
A. Identify and cleanse injection site closest to the patient
B. Administer correct dose at proper push rate
C. Turn IV on and adjust drip rate to TKO/KVO
Indications:
This procedure may be performed on any patient that requires the administration
of a medication.
Key procedural considerations (GENERAL):
A. Inquire about allergies and previous medication reactions
B. Check and recheck medication
C. Solution clarity and expiration date
D. Right drug
Right patient
Right dose
Right time
Right route
Right documentation
E. Dispose of syringe and other material in proper container
MEDICATION ADMINISTRATION (Cont.)
144
NEEDLE CRICOTHYROIDOTOMY
LEVEL: Paramedic
Indications:
This procedure may be performed on any patient with:
A. Total airway obstruction by any BLS or ALS procedures, OR
B. Inability to be adequately ventilate with any provider level emergency care
procedures prior to the attempt.
Contraindications:
A. Inability to identify landmarks (cricothyroid membrane)
B. Underlying anatomical abnormality (tumor)
C. Tracheal transection
D. Acute laryngeal disease due to infection or trauma
- Pediatric needle cricothyroidotomy is by Telemetry Physician order only.
- You MUST use a 14 gauge over-the-needle catheter attached to a 10 cc syringe
or commercial cricothyroidotomy device.
A. Position patient supine (if possible), hyperextending the head.
B. Locate cricothyroid membrane and clean site thoroughly.
C. Stabilize cricoid and thyroid cartilages with one hand.
D. Insert needle/catheter at a 45° angle; gently aspirate with attached syringe
while inserting.
E. When syringe is able to aspirate air, stop advancing needle.
F. Continue to advance catheter downward and withdraw needle.
G. Ventilate the patient allowing an inspiratory/expiratory ratio of 1:3.
H. Secure the device and auscultate lung fields.
I. Apply a 3-way stopcock to the end of the hose assembly when utilizing a
Transtracheal Jet Insufflator.
NEEDLE CRICOTHYROIDOTOMY
145
NEEDLE THORACENTESIS
LEVEL: Paramedic
Indications:
This procedure may be performed on any patient who has evidence of a
tension pneumothorax, demonstrated by the presence of:
Progressive respiratory distress and/or increased resistance to bagging, AND
unilateral diminished/absent breath sounds, associated with:
A. Tracheal deviation, or
B. Jugular venous distension, or
C. Signs of shock, low BP with chest trauma present
Needle Thoracentesis is permitted in pediatric patients.
A. Primary site is the 2nd intercostal space mid-clavicular line of the affected side.
B. Alternate location is the 4th- 5th intercostal space in the mid-axillary line of the
affected side.
C. Use a site specific, appropriate length needle to decompress the chest.
D. Prep site with iodine and/or alcohol.
E. Place tip of needle on top of appropriate rib and insert over top of rib into
intercostal space.
F. Advance catheter and remove needle.
G. Secure catheter and consider attaching a flutter valve assembly.
NEEDLE THORACENTESIS
146
TRACHEOSTOMY TUBE REPLACEMENT
LEVEL: Paramedic
Indications:
This procedure may be performed on any patient that has A TRACHEOSTOMY TUBE
and WHO HAS:
A. Hypoxia
C. Obtundation
D. Secretions unable to be cleared by suctioning
A. If the patient or family has a replacement tube available, it may be used. If a
replacement tube is not available, an endotracheal tube of a similar outer
diameter may be used.
B. Premoisten the tube with water soluble lubricant.
C. Extend the neck and, if necessary, place a roll between the patient’s shoulder
blades to aid in visualizing the stoma.
D. If the tube cannot be placed easily, withdraw the tube; administer oxygen and
positive pressure ventilation. NEVER force the tube.
E. Secure the device to the patient.
F. If the tube cannot be easily placed, a suction catheter may be used as a guide.
TRACHEOSTOMY TUBE REPLACEMENT
147
TRACTION SPLINT
Indications:
This procedure may be performed on any patient with an isolated closed midshaft
femur fracture.
Contraindications:
A. Pelvic fracture or instability
B. Knee, lower leg, or ankle instability
A. Assess motor, sensory, and circulatory function in the involved extremity.
B. Apply traction splint per the manufacturer’s guidelines.
C. Initiate mechanical traction to match manual traction.
D. Reassess motor, sensory, and circulatory function in the involved extremity.
TRACTION SPLINT
148
VAGAL MANEUVERS
LEVEL: Paramedic
The patient MUST be attached to a cardiac monitor
and MUST have vascular access prior to performing the procedure
Indications:
This procedure may be performed on any patient who is experiencing Supraventricular
Tachycardia with adequate perfusion.
Contraindications:
None
A. Approved methods include:
1. Valsalva maneuver
2. Head-down tilt with deep inspiration
3. Activation of the “diving reflex” by facial immersion in ice water (unless
ischemic heart disease is present)
4. Carotid massage (only on patients under 40 years of age)
B. In infants and young children, the most effective vagal maneuver is the application
of ice to the face. IV access is not mandatory prior to vagal maneuvers in children.
VAGAL MANEUVERS
149
VASCULAR ACCESS
LEVEL: AEMT/Paramedic
Vascular access attempts should not unnecessarily delay transport:
attempts should be completed en route.
All attempts are to be documented on the PCR.
Indications for Peripheral Vascular Access:
This procedure may be performed on any patient whenever there is a potential
need for:
A. Intravenous drug administration
B. Need to administer IV fluids for volume expansion
A. Saline locks may be used when appropriate and flushed with a 3 cc bolus of NS as
needed.
B. Extension tubing should be used on all IV lines.
Indications for Intraosseous Access (Paramedic/EMT-P only):
This procedure may be performed on any patient who requires IV drugs or IV fluids
AND who is:
A. Unconscious and unresponsive; and
B. Peripheral line cannot be immediately established.
Contraindications: Placement in, or distal to a fractured bone
Key procedural considerations: Only 1 (one) attempt is permitted per extremity
Indications for use of Previously Established Central Line Access:
This procedure may be performed on any critically ill or injured patient who requires IV drugs
or IV fluids AND in whom a peripheral line cannot be established.
Contraindications: Inability to freely aspirate blood out of the catheter.
Key procedural considerations: Central line access (Implantable Ports, Port-A-Caths, Medports)
A. May only be used if the device has already been accessed and IV fluid set-up has been
established and running.
B. These devices require special needles (non-coring type) for access. The device may be
damaged if standard jumper (conventional) needles are used to access the ports.
VASCULAR ACCESS
150
FORMULARY
151
ACETYLSALICYLIC ACID (Aspirin)
CLASS
Nonsteroidal anti-inflammatory (NSAID)
ACTION
Platelet inhibition
DOSE
Adult
324 mg PO (81 mg tablets x 4)
Pediatric
Not recommended for use
ROUTE
PO (chew and swallow)
CONTRAINDICATIONS
Allergy to Aspirin
ADVERSE REACTIONS
None
ACTIVATED CHARCOAL
CLASS
Adsorbent
ACTION
Inhibits gastrointestinal absorption of toxic substances
DOSE
Adult
50 gm PO
Pediatric
1.0 gm/kg PO; min. dose 10 gm; max. dose 50 gm
ROUTE
PO
CONTRAINDICATIONS
Altered mental status; ingestion of acids, alkalis or petroleum distillates; inability to swallow;
previous administration of an emetic
ADVERSE REACTIONS
Nausea; vomiting
152
ADENOSINE (Adenocard)
CLASS
Antiarrhythmic
ACTION
Slows conduction through the AV Node and can interrupt re-entry pathways
DOSE
Adult
6-12 mg, rapid IV push
Pediatric
0.2 mg/kg, rapid IV push, not to exceed 12 mg
ROUTE
Rapid IVP
CONTRAINDICATIONS
Second or third-degree AV block or sick sinus syndrome (unless patient with a functional
artificial pacemaker); atrial flutter; atrial fibrillation
Repeat doses of Adenosine are not indicated if the dysrhythmia reoccurs after conversion
Alternate pharmacological therapy may be necessary
ADVERSE REACTIONS
Facial flushing; headache; sweating; palpitations; chest pain
ALBUTEROL (Proventil)
CLASS
Sympathomimetic
ACTION
Bronchodilator
DOSE
Adult
2.5 mg in 3.0 ml SVN; repeat until improvement
Pediatric
2.5 mg in 3.0 ml SVN; repeat until improvement
ROUTE
Inhalation by oxygen nebulization
CONTRAINDICATIONS
Hypersensitivity to the drug
ADVERSE REACTIONS
Tachycardia; palpitations; anxiousness; headache
153
AMIODARONE (Cordarone)
CLASS
Antiarrhythmic
ACTION
Suppresses ventricular ectopy; increases ventricular fibrillation threshold
DOSE
Adult
300 mg IV/IO; may repeat one dose of 150 mg if refractory after 5th shock
Pediatric
5 mg/kg IV/IO; may repeat once after 5th shock
ROUTE
IV/IO
CONTRAINDICATIONS
Hypersensitivity to the drug; cardiogenic shock; high grade AV block; marked sinus bradycardia, or
bradycardia with ventricular escape beats
ADVERSE REACTIONS
Seizures; respiratory depression; dizziness; restlessness; confusion; tinnitus; blurred vision; numbness;
muscle twitching; hypotension; bradycardia; heart block; nausea; vomiting
ATROPINE SULFATE
CLASS
Parasympathetic blocker
ACTION
Cholinergic blocking agent; increases rate of SA node discharge; increases conduction
through AV node
DOSE
Adult
See specific protocol
Pediatric
ROUTE
IV/IO
CONTRAINDICATIONS
None
ADVERSE REACTIONS
None
154
BRONCHODILATOR METERED DOSE INHALER
CLASS
Sympathomimetic
ACTION
Bronchodilator
DOSE
Adult
Assist the patient in administering his or her own Bronchodilator Metered Dose Inhaler
exactly as prescribed.
Pediatric
Assist the patient in administering his or her own Bronchodilator Metered Dose Inhaler
exactly as prescribed.
ROUTE
Inhalation
CONTRAINDICATIONS
ADVERSE REACTIONS
Tachycardia; palpitations; anxiousness; headache
CALCIUM CHLORIDE
CLASS
Electrolyte
ACTION
Increases myocardial contractility; increases myocardial excitability; decreases heart rate
DOSE
Adult
1.0 gm (10% solution) slow IV/IO push
Pediatric
20 mg/kg (0.2 ml/kg of 10% solution) slow IV/IO push
ROUTE
Slow IVP
CONTRAINDICATIONS
Patients receiving digitalis
ADVERSE REACTIONS
None
155
DIAZEPAM (Valium)
CLASS
Antianxiety/Anticonvulsant
ACTION
CNS Depressant
DOSE
Adult
5.0 mg IV/IO may repeat titrating to effect
Pediatric
0.1 or 0.2 mg/kg IV/IO; maximum dose of 10 mg
0.5 mg/kg PR via #5 or 8 French feeding tube; maximum dose of 20 mg
ROUTE
IV/IO/PR
CONTRAINDICATIONS
Hypersensitivity; hypotension
ADVERSE REACTIONS
Respiratory depression; CNS depression; nausea; vomiting
DIPHENHYDRAMINE HYDROCHLORIDE (Benadryl)
CLASS
Antihistamine
ACTION
Blocks histamine receptors; has some sedative effects; anticholinergic
DOSE
Adult
50 mg IM/IV
Pediatric
1.0 mg/kg IM/IV, max. 50 mg
ROUTE
IV or deep IM
CONTRAINDICATIONS
ADVERSE REACTIONS
Sedation; palpitations; decreased blood pressure; headache; dries (thickens) bronchial secretions;
blurred vision
156
DOPAMINE HYDROCHLORIDE (Intropin)
CLASS
Sympathomimetic
ACTION
Positive inotrope with dose-related vascular effects
DOSE
Adult
5-20 mcg/kg/min; titrate to SBP >90mmHg
Pediatric
5-20 mcg/kg/min; titrate to SBP >70mmHg + 2 x age
ROUTE
IV by continuous infusion
CONTRAINDICATIONS
Hypovolemic shock
ADVERSE REACTIONS
Ventricular tachycardia; ectopic beats; nausea; vomiting; dyspnea; hypertension and extreme
vasoconstriction may occur with high infusion rates; hypotension may occur with low infusion rates
DROPERIDOL (Inapsine)
CLASS
Antiemetic
ACTION
Lowers incidence of nausea and vomiting
DOSE
Adult
1.25 mg IM/IV/IO followed by a saline flush or bolus; may repeat the dose after 5 minutes
Pediatric
Not indicated in patients under 12 years old
ROUTE
IM/IV/IO
CONTRAINDICATIONS
Patients with acute AMI; hypotensive patients; respiratory depression; hypersensitivity to Inapsine;
known prolonged QT interval
ADVERSE REACTIONS
EPS; syncope; cardiac dysrhythmias
157
EPINEPHRINE
CLASS
Sympathomimetic
ACTION
Bronchodilation; positive chronotrope; positive inotrope
DOSE
Adult
Pediatric
ROUTE
IM/IV/ETT/SVN
CONTRAINDICATIONS
Underlying cardiovascular disease/angina; hypertension; pregnancy; patient over 40 years of age;
hyperthyroidism
ADVERSE REACTIONS
Palpitation due to tachycardia or ectopic beats may produce arrhythmia if cardiac disease present;
elevation of blood pressure; headache; anxiousness
EPINEPHRINE AUTO-INJECTOR
CLASS
Sympathomimetic
ACTION
Bronchodilation; positive chronotrope; positive inotrope
DOSE
Adult
Assist patient with his or her own Epinephrine auto-injector
Pediatric
Assist patient with his or her own Epinephrine auto-injector
ROUTE
IM
CONTRAINDICATIONS
Underlying cardiovascular disease / angina; hypertension; pregnancy; patient over 40 years of age;
hyperthyroidism
ADVERSE REACTIONS
Palpitation due to tachycardia or ectopic beats may produce arrhythmia if cardiac disease present;
elevation of blood pressure; headache; anxiousness
158
ETOMIDATE (Amidate)
CLASS
Sedative / Hypnotic
ACTION
CNS depressant
DOSE
Adult
Induction 0.3 mg/kg IV; Sedation 0.15 mg/kg IV
Pediatric
Sedation 0.15 mg/kg IV
ROUTE
IV
CONTRAINDICATIONS
Known hypersensitivity to the drug
ADVERSE REACTIONS
Pain; transient skeletal movements; nausea; vomiting; hypoventilation; hypotension
FENTANYL CITRATE
CLASS
Analgesic
ACTION
CNS Depressant
DOSE
Adult
Up to 1.0 mcg/kg IN/IM/IV/IO, to a maximum single dose of 100 mcg. May repeat dose after 10 minutes.
Additional doses require physician order.
Pediatric
Up to 1.0 mcg/kg IN/IM/IV/IO, to a maximum single dose of 100 mcg. Additional doses require physician
order.
ROUTE
IN/IM/IV/IO
CONTRAINDICATIONS
Known hypersensitivity; patients less than two years old
ADVERSE REACTIONS
Respiratory depression; rapid infusion may produce “stiff chest syndrome”
159
GLUCAGON
CLASS
Insulin antagonist
ACTION
Reverses the effects of hypoglycemia
DOSE
Adult
1.0 mg IM for no IV access
Pediatric
ROUTE
IV/IM
CONTRAINDICATIONS
None
ADVERSE REACTIONS
Nausea; vomiting
GLUCOSE
CLASS
Carbohydrate
ACTION
Quick infusion of sugar into blood for metabolism
DOSE ORAL GLUCOSE
Adult
25 gm Glucose between the gum and cheek, if gag reflex is present.
Pediatric
Up 25 gm Glucose between the gum and cheek, if gag reflex is present and as tolerated.
DOSE D10 (10% Dextrose in 250 ml NS)
Adult
25 gm IV may repeat x1 in 5 minutes
Pediatric
5ml/kg IV max dose 250 ml
ROUTE
Slow IVP, IV drip or PO
CONTRAINDICATIONS
None
ADVERSE REACTIONS
None
160
Revised 4/2/2015
HYDROMORPHONE (Dilaudid)
CLASS
Analgesic
ACTION
CNS Depressant
DOSE
Adult
Up to 1.0 mg IM/IV/IO may repeat after 10 minutes. Additional doses require physician order.
Pediatric
Not for use in children under 12 years old
ROUTE
IM/IV/IO
CONTRAINDICATIONS
Known hypersensitivity; intolerance to opiate analgesics
ADVERSE REACTIONS
Respiratory depression
HYDROXOCOBALAMIN
CLASS
Detoxifying agent
ACTION
Competitively binds to cyanide ions
DOSE
Adult
5.0 g IV over 15 minutes
Pediatric
70 mg/kg IV over 15 minutes
ROUTE
IVPB
CONTRAINDICATIONS
None
ADVERSE REACTIONS
None
161
IPRATROPRIUM BROMIDE (Atrovent)
CLASS
Anticholinergic
ACTION
Appears to inhibit vagally mediated reflexes
DOSE
Adult
2.5 ml of 0.02% solution
Pediatric
2.5 ml of 0.02% solution
ROUTE
CONTRAINDICATIONS
Hypersensitivity to Ipratropruim
ADVERSE REACTIONS
Headache; nausea
IPRATROPRIUM BROMIDE and ALBUTEROL SULFATE (Duoneb)
CLASS
Anticholinergic/Sympathomimetic
ACTION
Appears to inhibit vagally mediated reflexes and acts as a bronchodilator
DOSE
Adult
3.0 ml
Pediatric
3.0 ml
ROUTE
CONTRAINDICATIONS
Hypersensitivity to either if the base medications
ADVERSE REACTIONS
Tachycardia; palpitations; anxiousness; headache; nausea
162
KETAMINE (Ketalar)
CLASS
General anesthetic/Induction agent
ACTION
CNS depressant
DOSE
Adult
0.2mg/kg IV/IO/IN
2.0 mg/kg IV/IO
4.0 mg/kg IM
Pediatric
2.0 mg/kg IV/IO
4.0 mg/kg IM
ROUTE
IM/IV/IO/IN
CONTRAINDICATIONS
Known hypersensitivity; systolic over 180 mmHg; acute CVA; head trauma
ADVERSE REACTIONS
Respiratory depression
LIDOCAINE (Xylocaine) 2% LUBRICANT
CLASS
Topical anesthetic
ACTION
Produces anesthesia by interfering with nervous system transmission
ROUTE
Topical use only
CONTRAINDICATIONS
ADVERSE REACTIONS
Seizures; respiratory depression; dizziness; restlessness; confusion; tinnitus; blurred vision; numbness;
muscle twitching; hypotension; bradycardia; heart block; nausea; vomiting
163
MAGNESIUM SULFATE
CLASS
Electrolyte
ACTION
Membrane stabilization; raises seizure threshold
DOSE
Adult
2.0 gm in 50 cc NS over 10 minutes IV/IO
Pediatric
25 mg/kg in 50 cc NS over 10 minutes IV/IO
ROUTE
Medical: Mixed in 50 cc NS IV piggyback
Cardiac: Slow IVP
CONTRAINDICATIONS
Hypersensitivity to the drug; high degree heart block; renal failure
ADVERSE REACTIONS
Hypotension; asystole; respiratory depression; weakness
MIDAZOLAM (Versed)
CLASS
Anxiolytic
ACTION
CNS depressant
DOSE
Adult
0.1 mg/kg IN/IM/IV; may repeat after 5 minutes at 0.05 mg/kg IN/IM/IV
Pediatric
If patient is less than 12 yrs of age, 0.1 mg/kg IN/IV, titrated to effect, max single dose
5.0 mg; must be given slowly over a period of 3-5 minutes; additional doses by telemetry
physician order only.
ROUTE
Slow IVP, PR/IN/IM
CONTRAINDICATIONS
Hypersensitivity to the drug; hypotension; clinical signs of shock
ADVERSE REACTIONS
CNS depression; hypotension, respiratory depression
164
MORPHINE SULFATE
CLASS
Narcotic
ACTION
CNS depressant
DOSE
Adult
0.1 mg/kg IM, slow IV, to a max single dose of 10 mg; may repeat at 10 minute intervals until pain
is relieved or respiratory/mental status depression occur.
Pediatric
0.1 mg/kg IM, slow IV, to a max single dose of 10 mg. Additional doses by telemetry physician order only.
ROUTE
IM, Slow IVP
CONTRAINDICATIONS
Hypersensitivity to opiates; head injuries; chest or abdominal injury; clinical signs of shock
ADVERSE REACTIONS
Respiratory depression; nausea; vomiting; bradycardia; orthostatic hypotension; altered level of consciousness
NALOXONE HYDROCHLORIDE (Narcan)
CLASS
Narcotic antagonist
ACTION
Reverses effects of narcotics
DOSE
Adult
0.4 - 2.0 mg IN/IM/IV; may repeat 2.0 mg IN/IM/IV if patient slow to respond; titrate to effect;
max dose 10 mg.
Pediatric
0.1 mg/kg IN/IM/IV; may repeat if patient slow to respond; titrate to effect; max single dose 2.0 mg;
max total dose 10 mg.
ROUTE
IN/IM/IV
CONTRAINDICATIONS
Patients with a history of hypersensitivity to the drug; intubated patients; the newly born during
initial resuscitation
ADVERSE REACTIONS
Rapid administration causes projectile vomiting
165
NITROGLYCERIN
CLASS
Vasodilator
ACTION
Dilates systemic arteries and veins; reduces both preload and afterload
DOSE
Adult
Pediatric
ROUTE
Sublingual spray or tablet
CONTRAINDICATIONS
Hypotension (do not administer if systolic pressure below 100 mmHg unless ordered by a physician);
use of Viagra (Sildenafil) or similar medication within the past 24 hours or 48 hours for Tadalafil (Cialis);
patients with demonstrated hypersensitivity to nitrates or nitrites
ADVERSE REACTIONS
Hypotension
ONDANSETRON HYDROCHLORIDE (Zofran)
CLASS
Selective serotonin blocking agent
ACTION
Antiemetic
DOSE
Adult
4.0 mg ODT/IM/IV
Pediatric
0.15 mg/kg ODT up to a max dose of 4 mg (round up to the nearest ½ pill)
ROUTE
Slow IVP/IM/ODT
CONTRAINDICATIONS
Patients with a known hypersensitivity to the drug
ADVERSE REACTIONS
Headache; chest pain; dizziness; hypotension
166
PHENYLEPHRINE (Neo-Synephrine)
CLASS
Sympathomimetic
ACTION
Direct local vasoconstriction
DOSE
Adult
2-3 drops or 1-2 sprays in each nostril, and Lidocaine 2% lubricant
Pediatric
Not recommended for use
ROUTE
IN
CONTRAINDICATIONS
Ventricular tachycardia; severe coronary artery disease; head injured patients with altered mental status
ADVERSE REACTIONS
None
SODIUM BICARBONATE
CLASS
Alkalinizing agent
ACTION
Increases blood pH
DOSE
Adult
1.0 mEq/kg; 50mEq/50 ml (8.4% solution) IV
Pediatric
1.0 ml/kg; 50mEq/50 ml (8.4% solution) IV/IO (use 4.2% solution for neonatal patients)
ROUTE
IV/IO
CONTRAINDICATIONS
Alkalotic states; respiratory acidosis
ADVERSE REACTIONS
None
167
Solu-Cortef (Hydrocortisone Sodium Succinate)
CLASS
Corticosteroid
ACTION
Anti-inflammatory, replaces absent glucocorticoids, suppresses immune response
DOSE
Adult
As prescribed (usual dose 100mg)
Pediatric
As prescribed (usual dose 2 mg/kg to a max of 100 mg)
ROUTE
IM or Slow IV/IO over 30 seconds
CONTRAINDICATIONS
Systemic fungal infections, hypersensitivity to the drug
ADVERSE REACTIONS
ECG changes, hypertension, headache
USING THE ACT-O-VIAL
Press down on plastic activator to force diluent into the lower compartment
Gently agitate to effect solution
Remove plastic tab covering center of stopper
Swab top of stopper with a suitable antiseptic
Insert needle squarely through center of plunger-stopper until tip is just visible. Invert vial and withdraw the
required dose.
168
First Response Low-Risk Alpha Evaluate and Release Form (example)
Incident #:
EMS Agency:
Patient Name:
Date of Birth:
Address:
Phone #:
Responding Ambulance Service:
AMR
MW
Community Ambulance
Medical Priority Dispatch System Code:
Time of Patient Contact:
Patient Complaint(s):
Primary Survey Complete
Secondary Survey Complete
Vital Signs: HR ________ RR_________ BP_________ SPO2_________ BG (as applicable)_________
General Impression:
Confirm the following:
Normal vital signs
Time last taken:
Patient does not meet Trauma Field Triage Criteria
No indication for an ECG or cardiac monitoring per SNHD Emergency Medical Care Protocols
Patient is not a threat to self or others
Patient denies AND no evidence or suspicion of the following:
Pregnancy
Head trauma
Chest pain
Active bleeding
Seizure
Stroke
Allergic reaction
Shortness of breath
Syncope, near syncope, or dizziness
Overdose or investional error
Abdominal pain/flank pain above the
Umbilicus if >35 years of age
Inclusion Criteria:
Call coded and dispatched using MPDS, Alpha or Omega category
Patient between 18 and 65 years of age
Patient has decision making capacity
Patient has a phone to call 9-1-1 if their condition worsens
We have assessed and examined you and have determined your condition as NOT THREATENING TO LIFE/LIMB.
With your permission, we will return to service so we may be available in the case of another emergency. An
ambulance is continuing to respond. If your condition worsens in any way, call 9-1-1.
I consent to waiting for the ambulance and understand that I can call 9-1-1 if I get worse
in any way.
Patient signature
Provider signature
SAMPLE ALGORITHM, RELEASE OF MEDICAL
ASSISTANCE
Describe proposed plan of
treatment
Agrees?
Initiate Care
Yes
No
Yes
EMS Personnel suspect compromise in
judgment in presence of life/limb threatening
injury/illness?
Yes
Initiate care
under implied
consent
Yes
Explain &
document
specific risks of
refusal
No
Patient is an adult or an emancipated minor
and has decision-making capacity?
No
Enlist help of
others as
appropriate (PD,
friends, family,
medical control)
Guardian available? (Consider cellular or
dispatch assisted contact)
No
Rational teen
in low risk
situation?
Yes
Accept
Waiver
Yes
Patient willing to sign
waiver?
No
No
Initiate care under implied
consent
Document efforts and
patient’s refusal to sign
Note:
1. For all patients refusing transport who meet Trauma Field Triage Criteria protocol,
contact a trauma center.
2. EMS personnel may make telemetry contact for further guidance at any time.
B2
SCOPE OF PRACTICE
Authorized Medication List
The following is the fomulary used by EMS agencies in Clark County. Licensed EMS providers working in
the EMS System for a permitted agency are authorized, within their level of certification and training, to
administer medications as directed by the written treatment protocols.
Medications
Acetylsalicylic
Acid
Acetylsalicylic Acid
Activated Charcoal
Adenosine
Albuterol
Amiodarone
Atropine Sulfate
Bronchodilator Metered Dose Inhaler
Calcium Chloride
Diazepam
Diphenhydramine Hydrochloride
Dopamine Hydrochloride
Droperidol
Epinephrine
Epinephrine Autoinjector
Etomidate
Fentanyl Citrate
Glucagon
Glucose - Oral
Glucose Sterile Injectable
Hydromorphone
Hydroxocobalamin
Ipratroprium Bromide
Ipratroprium Bromide & Albuterol Sulfate
Ketamine
Lidocaine 2% Lubricant
Magnesium Sulfate
Midazolam
Morphine Sulfate
Naloxone Hydrochloride
Nitroglycerin
Ondansetron Hydrochloride
Phenylephrine
Sodium Bicarbonate
Solu-Cortef
EMT
X
X
AEMT
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
C1
Paramedic
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
SCOPE OF PRACTICE
Authorized Skills List
The following are the authorized skills used by EMS providers in Clark County. Licensed EMS providers
working in the EMS System for a permitted agency are authorized, within their level of certification and
training, to perform the skills as directed by the written treatment protocols.
Skills
12-Lead
ECG
Interpretation
12-Lead ECG Interpretation
3-Lead ECG Interpretation
Airway Adjunct - NPA
Airway Adjunct - OPA/NPA
Airway Suction
Capnometry (Color Change Device)
Capnometry (Continuous Waveform)
Carotid Massage
CPAP
CPR
Defibrillation - AED
Defibrillation - Manual
Endotracheal Intubation - Nasal
Endotracheal Intubation - Oral
Gastric Decompression
Glucose Measurement
Induced Hypothermia
Medication Administration
Needle Cricothyroidotomy
Oxygen Administration
Patient Assessment
Pulse Oximetry
Restraints
Splinting
Stroke Screen
Supgraglottic Airway Device
Synchronized Cardioversion
Thermometer
Transcutaneous Pacing
Vagal Maneuvers
Vascular Access IV
Vascular Access IO
EMT
AEMT
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
C2
Paramedic
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Southe rn N e va da H e a lth D is tric t
O ffic e of E m e rg e nc y M e dic a l Se rvic e s a nd T ra um a Sys te m
SU B JE C T : R e c e iving H os pita l D ire c tory
Th i s d i r ec to r y i s s u b j ec t to c h a n g e a n d i s p r o v i d ed fo r i n fo r m a ti o n a l p u r p o s es o n l y
H O S P I TAL N AM E
AD D R ES S
PHO NE
B o u ld e r City Ho s p ita l
9 0 1 A d a ms B lv d
B o u ld e r City , NV 8 9 0 0 5
(702) 293-4111
Ce n te n n ia l Hills Ho s p ita l
6 9 0 0 No r th Du r a n g o Dr
L a s V e g a s , NV 8 9 1 4 9 - 4 4 0 9
(702) 360-9040
De s e r t S p r in g s Ho s p ita l
2 0 7 5 E. Fla min g o Rd .
L a s V e g a s , NV 8 9 1 1 9
(702) 733-8800
HO SP
CO DE
TR AU M A
LEV EL
BURN
C EN TER
S TR O K E
H YP O D ES T
TH ER M I A
P ED S
D ES T
Mo u n ta in V ie w Ho s p ita l
3 1 0 0 N Te n a y a W a y
L a s V e g a s , NV 8 9 1 2 8
(702) 255-5025
No r th V is ta Ho s p ita l
1 4 0 9 Ea s t L a ke Me a d B lv d
No r th L a s V e g a s , NV 8 9 0 3 0
(702) 649-7711
H -1 9
X
X
H -2
X
X
X
X
X
X
X
X
H -3
H -1 1
X
X
X
H -5
S o u th e r n Hills Ho s p ita l
9 3 0 0 W . S u n s e t Ro a d
L a s V e g a s , NV 8 9 1 4 8
(702) 880-2100
H -1 6
X
X
X
X
S p r in g V a lle y Ho s p ita l
5 4 0 0 S o u th Ra in b o w B lv d
L a s V e g a s , NV 8 9 1 1 8
(702) 853-3000
H -1 5
X
X
X
X
H -7
X
X
H -7 3
X
S t. Ro s e d e L ima
1 0 2 E. L a ke Me a d Pkw y
He n d e r s o n , NV 8 9 0 1 5
(702) 616-5000
S t. Ro s e S a n Ma r tin
8 2 8 0 W e s t W a r m S p r in g s Rd
L a s V e g a s , NV 8 9 1 1 3
(702) 492-8000
S t. Ro s e S ie n a
3 0 0 1 S t. Ro s e Pkw y
He n d e r s o n , NV 8 9 0 5 2
(702) 616-5000
S u mme r lin Me d ic a l Ce n te r
6 5 7 To w n Ce n te r Dr .
L a s V e g a s , NV 8 9 1 4 4
(702) 233-7000
H -7 2
(-T/-P )
Lev el I I I
H -1
(-P )
S u n r is e Ho s p ita l
3 1 8 6 S o u th Ma r y la n d Pkw y
L a s V e g a s , NV 8 9 1 0 9
(702) 731-8000
H -6
(-T/-P )
Lev el I I
Un iv e r s ity Me d ic a l Ce n te r
1 8 0 0 W . Ch a r le s to n B lv d
L a s V e g a s , NV 8 9 1 0 2
(702) 383-2000
H -4
(-T/-P )
Lev el I
P ed i a tr i c
Lev el I I
V a lle y Ho s p ita l
620 Shadow Lane
L a s V e g a s ,, NV 8 9 1 0 6
(702) 388-4000
H O S P I TAL N AM E
AD D R ES S
PHO NE
S P EC I AL S ER V I C ES
X
H -8
Me s a V ie w Ho s p ita l
1 2 9 9 B e r th a Ho w e A v e n u e
Me s q u ite , NV 8 9 0 2 7
(702) 346-8040
Mike O ’Ca lla g h a n Fe d e r a l Ho s p ita l
4 7 0 0 L a s V e g a s B lv d N
Ne llis A FB , NV 8 9 1 9 1 - 6 6 0 0
(702) 653-2343
L & D H ELI P AD
X
H -9
HO SP
CO DE
TR AU M A
LEV EL
BURN
C EN TER
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
S A Ev a l u a ti o n
(P a ti en ts < 1 3 y /o )
X
X
X
X
X
S A Ev a l u a ti o n
(P a ti en ts > 1 8 y /o )
X
X
S TR O K E
H YP O D ES T
TH ER M I A
X
P ED S
D ES T
L & D H ELI P AD
S P EC I AL S ER V I C ES

Emergency Medical Care Protocols - Southern Nevada Health District

Transcription

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